More useful national and international resources, debates and references to guide GSAHS

The following useful resources each advocate action different from that taken by the previous government regarding maternity services at Pambula hospital. It is hoped that the current government is aware of the strength of argument contained in these international resources.

Jeremy Sammut uncovers the real issue and a solution: Hospital overhaul is our only hope

The PM has been heavily criticised for delaying hospital reform until some time in the first half of this year. But his government's round of Australia-wide consultation meetings in public hospitals in the past six months has drawn attention to the key issues.

Doctors and nurses have told how frustrated they are working for unresponsive state departments such as NSW Health and Queensland Health.

In these states in particular, frontline staff are sick of patient care remaining under- resourced while money is squandered on the salaries and perks of an army of managers warehoused in the area health services.

Download the PDF

3.03pm Wednesday 03 February 2010

Visit Orbost - An Ideal Model of Rural Health Care Provision.

It's not too far by road and only a click away on the net.

There you will find lots of advice that could help you fix the problems you have caused at Pambula Hospital.

Item 1 - Item 2 - Item 3

Private cures for public woes

The Prime Minister promised in 2007 to take control of the public hospitals if their performance didn't improve. We're yet to see that improvement: in fact, average national waiting times for elective surgery rose in 2009 from 34 to 36 days.

Despite this, federal control of public hospitals seems a long way off. Yet there is a simple solution that doesn't require major reform.

That is, to better use the available capacity of non-government private hospitals to treat public patients who have endured unreasonable waits for elective surgery.

The government's experts at the National Health and Hospital Reform Commission failed to examine the opportunity to use the capacity of non-government not-for-profit hospitals. In fact, the commission hardly focused on the private hospital sector atall.

Those working on the government's plan for the future of the nation's hospital system would be wise to take a closer look at non-governmenthospitals. Not only do they operate at a high standard of quality, they may save taxpayers' dollars.

Read lots more

Objective. To examine the effect of rural hospital closures on the local economy.Principal Findings. Results indicate that the closure of the sole hospital in the community reduces per-capita income by $703 (p<0.05) or 4 percent (p<0.05) and increases the unemployment rate by 1.6 percentage points (p<0.01). Closures in communities with alternative sources of hospital care had no long-term economic impact, although income decreased for 2 years following the closure.

Conclusions. The local economic effects of a hospital closure should be considered when regulations that affect hospitals' financial well-being are designed or changed.

Rural Maternity Services - The Australian College of Midwives - February 2007

The Australian College of Midwives (ACM) believe that the closure of maternity services in rural areas and resultant lack of provision of care for women in these areas is an unacceptable situation. It is the view of the Australian College of Midwives that there is an urgent need for the development of a National Framework for Maternity Services to guide a range of initiatives which will improve access to maternity care for women in rural areas.Figures indicate that around 130 rural services from across Australia have closed in the last 10 years however figures also indicate that the birth rate is rising and people are choosing to move to country areas for the lifestyle.

Closing small maternity units puts the responsibility for accessing maternity care back to the clients. The ACM believe that maternity service providers should take the responsibility to provide maternity care on an equal and equitable basis to all women regardless of their location. Closure of rural services is only one way of dealing with workforce shortages and no formal examination of the safety and cost effectiveness of this method of dealing with this situation has occurred. Evidence indicates that smaller maternity units are, at least, as safe as larger units. Evidence does not indicate the need for all services (eg caesarean section capability) to be available on all sites of a rural unit.

National roundtable hears practical solutions to rural health workforce crisis - Tuesday 19 February 2008

Many rural Australians are now waiting six weeks or more for a standard medical consultation, while others are
having to drive hundreds of kilometres to access basic healthcare. This is at a time when rural Australians have
much worse health outcomes than those living in the cities, including significantly lower life expectancies. The
relentless downgrading or closure of rural hospitals and other rural health services also continues unabated. For
example, 50% of all rural maternity units across Australia have been closed in the past decade alone, forcing many rural women to travel long distances to give birth elsewhere.

RDAV Position Statement On Small Unit Rural Obstetrics - February 2002

The persistent tendency for smaller rural obstetric units to close in Victoria is a significant component of rural rundown. There were over 40 of 123 unit closures in the years 1983 to 1997

Safe confinement facilities close to home are an essential component of viable Australian rural community and economy. Rural viability requires minimum disruption to family life and rural industry. The prime objective of a healthy mother and baby must be met by the safest possible obstetric system. Repeated studies have shown small rural units, however small to have substantially better outcomes and are cheaper per confinement than metropolitan or provincial units. The corollary is that closure leads to increasing morbidity and mortality. There is not and never has been any valid argument for closure of small rural obstetric units on grounds of safety or smallness. The wishes of mothers must be respected and facilities provided.

President of the Rural Doctors Association of Australia (RDAA), Dr Peter Rischbieth

Every year, millions of taxpayer and health insurance dollars pour out of rural Australia to subsidise metropolitan services. At the same time, governments have been closing or downgrading rural hospital services and largely standing by and watching as doctors leave the bush. Over 130 small rural maternity units have been closed across Australia in the past decade alone. It is time that this blatant, annual grab of cash from rural communities stops and the federal and state governments work together to ensure that rural dollars are invested back into rural health services. Introducing a Rural Service Obligation for rural health services would be a key way to ensure this. Key measures required in meeting the obligation would include:

• ensuring that small rural hospitals and their maternity, general surgery, emergency and other procedural services are available within 30-60 minutes of all rural communities, and that rural hospitals receive an annual Commonwealth entitlement directly rewarding them for keeping these important services open.introducing additional supports to entice many more young doctors and Australian-trained medical graduates to take up rural practice. There is also an urgent need to better support the overseas trained doctors who provide such fantastic service in our rural communities.funding many more procedural training places annually in regional and rural hospitals to entice more young medical graduates and rural doctors to undertake training in rural procedural medicine, ie. obstetrics, anaesthetics, general surgery and emergency medicine.
• introducing additional supports and incentives, such as fee for service incentives, to encourage existing rural doctors to keep working in the bush and to show young doctors and recent graduates that rural practice can be a most rewarding career choice.

Rural hospitals need a public interest test - By Michael Condon - ABC Rural - Thursday, 27/07/2006

Merely looking at the economics of a hospital is no longer good enough, and the AMA is calling on all Australian governments to apply a public interest test before downgrading or closing any more public hospitals in rural areas. The Australian Medical Association says that the bean counters in government have been given too much power of decision making and after years of neglect governments should do whatever it takes to keep country public hospitals operating and properly resourced and staffed.

Come clean on Country Health Care Plan, Minister - The Rural Doctors Association of South Australia (RDASA)

“When a pregnant woman is turned away from her local hospital at the onset of labour—because that hospital
is no longer allowed to provide obstetric care—and told to drive two hours to the next closest hospital, will she
really believe health services in her area are better than they were before?

Doctors Welcome Nationals’ Proposal on Rural Hospital Funding - The Rural Doctors Association of Australia (RDAA)

“Closing and downgrading small rural hospitals places further pressure on larger regional hospitals, and discourages doctors from moving to rural areas. It also diminishes the local capacity to handle emergencies, which can have a critical impact on the ability to cope with serious road and farming accidents.“Small rural hospitals are often also the only places where nursing and allied health services are available in a rural community and where you receive chronic care treatment such as for a diabetic foot ulcer or rehabilitation following a stroke.

“In short, small rural hospitals provide an essential service to rural communities. It is equally essential that the other major parties, both at the federal and state levels, now follow the Nationals’ lead and commit to quarantining specific funding in the Australian Health Care Agreements to help save them.”

RESPONSE TO DISCUSSION PAPER: IMPROVING MATERNITY SERVICES IN AUSTRALIA - The Rural Doctors Association of Queensland (RDAQ)

In the absence of a maternity service, women are less likely to access ante-natal care; and there is the potential for unsupported roadside deliveries with associated dangers, not to mention the traffic hazards involved when anxious drivers negotiate country roads at high speeds in an emergency. Downgrading rural maternity services inevitably results in increased danger to those women who do not have the option of moving away from their family and community, especially as the local capacity to provide emergency treatment declines.

The contribution that an effective health service makes to the economic and social fabric of rural communities should not be underestimated. Not only do health services provide direct employment opportunities, and generate income, but their existence makes it possible for other businesses and industries to attract and retain a workforce.

Maternity Services for Rural Autralia - Preamble - Rural Doctor's Association of Australia

Rural women have the right to choose birthing at hospitals in their own communities supported by their family and friends and continuity of care from their local maternity service. Robust evidence shows that small rural hospitals are safe places to give birth. Yet despite their proud record, more than 130 rural maternity units have been closed since 1995. The Rural Doctors Association of Australia (RDAA) asserts that the three major issues related to these closures - safety, workforce and cost - must be examined in the light of current evidence and vigorously addressed as a matter of urgency.Crucial Issues

Risk-adjusted data show that obstetric outcomes in small maternity units are as good as, and often better than, those achieved in larger hospitals. RDAA contends that it is closing local birthing services that compromises the safety of rural mothers by forcing them to travel elsewhere to give birth. Closing rural maternity units exacerbates workforce shortages by undermining government workforce policies and programs that support the recruitment and training of GP proceduralists when the rural maternity units in which they could practise are closed. Hospitals, health authorities and health departments may anticipate savings through closing rural maternity units. However, in broader terms, this is not cost-effective because:

• delivery costs are usually lower in smaller hospitalsclosure shifts costs from the health budget to rural families and communities in the form of transport, accommodation, loss of income due to absence from a farm or other employment and spending diverted from local businessesthe local hospital is an important employer, sometimes the largest employer, in a small town. Its downgrading or closure has a significant impact on the socio-economic vitality of the communitythe larger hospitals where mothers have to go to give birth incur increased costs, often without commensurate increases in human or financial resources
• ambulance services face higher costs, workloads and responsibilities, frequently without the increased funds, staff or training needed to cover them

Safe and cost-effective services - RDAA asserts that the following basic requirements are essential for the safe and cost-effective delivery of safe maternity care for rural communities:

• continuity of care within the mother’s community during pregnancy, birth and the postnatal period which enhances safety, bolsters patient satisfaction and reinforces professional job satisfactionappropriately trained and properly supported procedural doctors, midwives and multi-skilled rural nurses working collaboratively in flexible, locally developed team models of care that utilise the skills of all the team efficiently and incorporate rural and regional specialistslocal birthing teams backed by reliable 24 hour advisory and referral networks, ambulance services and retrieval systemslocal hospitals and community based services that are adequately funded, staffed and equipped for safe birthing careplanning based on community need, rather than predominantly budgetary considerations
• an evidence-based framework for service delivery developed in consultation with rural communities and rural healthcare providers

Heike Roth - Student midwife - Improving Maternity Services in Australia: A Discussion Paper from the Australian Government

By closing these small rural birthing units, maternity service providers now put the responsibility in the woman’s court, when really maternity care should be available on an equal and equitable basis to all women regardless of their location and cultural background (ACMI, 2007). Women living in rural and remote areas often travel long distances to access basic local maternity services. Cost of travel, possibly lost wages, childcare costs and out-of-pocket fees often need to be considered and this basic maternity care suddenly comes at a substantial and often unaffordable cost (Kildea, 2003). As a result, some women may choose to avoid antenatal care (NRHA, 2006).

National Rural Health Alliance - Position Paper - Principles for maternity services in rural and remote Australia reallocated by state health authorities to other services.

The closure of local maternity services has shifted significant risk to families and away from health services: there is an increased chance of birth occurring outside the appropriate care setting, a higher risk of associated complications, and greater costs (in time and money) to be borne by the mother and her family. The costs are incurred through increased travel and accommodation away from home (with concomitant family dislocation). Funds saved by closures have presumably been

The effects of these changes, both short and longer term, constitute a significant elevation and transfer of risk and diminution of the equity of access for rural and remote people.

Authors come from Australian Institute of Health and Welfare (AIHW), National Perinatal Statistics Unit, University of New South Wales, Royal Prince Alfred and Liverpool Hospitals, School of Public Health and Community Medicine, University of New South Wales, Neonatal Intensive Care Unit, Nepean Hospital.Does size matter? A population-based study of birth in lower volume maternity hospitals for low risk women

Conclusions In Australia, lower hospital volume is not associated with adverse outcomes for low risk women.

Australian College of Rural and Remote Medicine and the Rural Doctor's Association of Queensland. November 2004

...evidence from NSW shows that closure of rural maternity units lead to poor outcomes. "...there was a high proportion of low birth-weight infants, stillbirths and neonatal deaths" in towns where maternity services had been withdrawn.Their report concluded...

Small rural obstetric units need to be supported and re-established as the safest delivery option for rural women. When they are closed, the associated social and economic effects lead directly to quantifiable increases in perinatal mortality.

Piper B.  Cutting costs at the expense of rural communities - is it all dollars and no sense? Rural and Remote Health 5 (online), 2005.

"Small rural hospitals must be utilized as centers of quality health care and training and their future directed by a focus on health outcomes and community sustainability rather than purely financial considerations."

A National Consensus Framework For Rural Maternity Services: From The Rural Doctors Association of Australia, The Australian College of Rural and Remote Medicine, The Australian College of Midwives, The Royal Australian & New Zealand College of Obstetricians and Gynaecologists, The Royal Australian College of General Practitioners, Rural Health Workforce Australia.

“Women should have access to safe maternity care, consistent with their assessed level of risk, as close as possible to where they live.”

Good Health for Victorian Rural Communities: A consensus statement of the Country Women’s Association of Victoria, Rural Doctors Association of Victoria, Victorian Farmers Federation.

“It is universally accepted that travel to urgent medical care in excess of a ½ hour from onset substantially increases risk of complications in trauma, medical conditions and obstetric labour.”

Response to Improving Maternity Services in Australia - October 31 2008 - Royal Australian College of General Practitioners.

”The RACGP believes one of the most influential drivers of higher intervention rates is the closure of smaller maternity units. 50% of all rural maternity units across Australia have been closed in the past 12 years, forcing thousands of rural and remote women to travel to distant centres to give birth. There is data demonstrating that smaller maternity units have excellent outcomes in terms of lower rates of interventions and maternal and perinatal mortality and morbidity. With data matching to compare the outcomes of low risk pregnancies in large maternity units and smaller maternity units, smaller units consistently provide better outcomes.”

The Rural Health Education Foundation - Four Corners: Far From Care

“The outcomes of rural birthing units are the best in Australia - the babies of case-matched low risk mothers are three times less likely to die in units of 100-500 size than in hospitals delivering being >2000 per year.”

Improving Maternity Services in Australia, Charles Darwin University, Graduate School of Health Practice Response - Prepared by: Prof Lesley Barclay, Ms Cath Farrington, Dr Sue Kildea, Dr Sue Kruske

What key infrastructure is needed?

• Funding systems with incentives and disincentives that promote normal health birthSmall units and hospitals and clinics capable of managing healthy birth close to rural and remote populations. These exist currently and would take little additional funding or equipping to work totally satisfactorily. This would relive unacceptable pressures on large hospitals currently overwhelmed with increased births forced into them by the closure of the smaller units.
• Smooth referral pathways and evacuation plans and travel operational easily and efficiently

http://www.ama.com.au/system/files/node/4126/Rural_Policy_Paper.pdf.

“The AMA believes that the standards of health care can be lifted in regional, rural and remote Australia. The communities there are already served by highly skilled doctors who often work long hours and who are totally dedicated to the needs of their community. The work is challenging and can be very rewarding. These doctors are valued by their communities and there is no doubt that many doctors enjoy the sense of community and lifestyle. Political parties therefore ignore rural health care issues at their peril.”

Australian College of Midwives: Dr Pat Brodie (President) - Media Release - Wednesday 7 December 2005

“The study also found that low risk women having babies in maternity units with less than 100 births a year had significantly fewer inductions, epidurals, forceps/vacuum births, emergency caesareans and babies being admitted to a neonatal unit, compared with low risk women giving birth in maternity units with greater than 2000 births a year.‘It is clear that in Australia, a lower hospital volume is not associated with adverse outcomes for low risk women and their babies’ Dr Tracy said, ‘in fact, it appears these women are better off. They have more normal births and lower levels of intervention in the birth. There is plenty of research to say this is a good thing.’

Closure of small rural hospitals has an undoubtedly negative effect on communities. ‘The maternity unit is often the heart of a community. It provides many women with the opportunity to give birth close to where they live without separation from their families and at no greater public cost’, said Professor Pat Brodie, National President of the Australian College of Midwives.”

Federal Election Position - Statement 2007

“Rural Australians should be able to expect country towns will have access to a rural generalist doctor, accident and emergency services, maternity services, and essential medical and surgical facilities at their local hospital.”

“Maternity Services are an essential component for thriving rural communities. Expectant mothers should be able to have their babies close to home, where they are able to access the support available in their local communities. Rural hospitals should, within a regionalised risk management system, offer maternity care services to a low-risk population. It is expected that small maternity units will be networked with larger regional maternity services to provide a coordinated and high quality maternity service within a region”

Federal Budget Submission - 2009/10

The RDAA has previously called for both Federal and State governments to implement a Rural Health Obligation in the next round of the Australian Health Care Agreements. This would establish minimum service obligations to ensure rural Australians have better access to rural doctors, local hospitals and rural health services. People living in rural Australia should be guaranteed that when they have a heart attack, are injured in a farming or road accident or have a baby they can access health services locally.

“The provision of maternity services in rural communities is like the ‘canary in the coalmine’ for these communities - whilst these services remain it tends to indicate that these communities are sustainable and that the local hospital provides a good range of services to their community. When the maternity service closes then it adversely affects the ability of the community to attract families and often signals the ultimate closure of the procedural services at the local hospital.”

National Rural Health Alliance E-forum 21 November 2008

Call for moratorium on rural maternity service closures

The peak non-government body for rural and remote health has called for a moratorium on the closure of maternity services in rural and regional communities. “The fact that rural birthing options are becoming increasingly limited is of great concern to families and rural communities and ought to be a matter of concern to the health sector, the Treasury and society at large,” the National Rural Health Alliance said in a submission to the Rudd Government’s National Maternity Services Review.

Submitted To The Federal Office For Women By The National Rural Women’s Coalition - December 2008

“There have been a number of policies introduced in recent years that have swiftly and dramatically affected the lives of women in rural and remote areas. A very good example is in the area of health service delivery. Over 130 maternity services have been closed in the last decade, most in rural and remote areas. While these are mostly the responsibility of state governments, the Commonwealth should use its funding agreements with the States/Territories to offer financial incentives to sustain and expand rural maternity services and to penalise States when units are closed without proper consultation and without a social impact assessment. There are some women in Australia now giving birth on the side of the road in dramatic circumstances and there are many travelling long distances on poor roads in labour, significantly increasing the risks for women and babies. These risks far outweigh those of giving birth in a small rural maternity centre. This policy failure is one of the most extraordinary examples of an attack on the human rights of Australian women. In research conducted at Charles Sturt University it was discovered that many women in remote areas are also using all their baby bonus money on travel and accommodation to give birth."

NSW Midwives Association - Acute Care Services in NSW Public Hospitals - March 28th - 2008

“NSWMA is concerned about closure of small maternity units in recent years and the continued questions being raised about the safety of giving birth in small units. Closures of small maternity services over the past decade have had a devastating effect on many communities and caused more babies to be born by the roadside. Such closures fly in the face of the latest evidence about the safety of small maternity units. A recent landmark, Australian study published in the British Journal of Obstetrics and Gynaecology (January 2006) showed that low risk pregnant women can now be reassured that giving birth in small maternity units in Australia is safe.”

Professor Caroline de Costa and Dr Paul Howat, James Cook University School of Medicine and Cairns Base Hospital, Cairns, Queensland.

“The past few years have seen the closure of maternity units at Weipa, Cooktown, Mossman and Tully and the limitation to a midwife-lead service at Mareeba. Women from Cape York and much of the Tablelands and Daintree regions who have low-risk pregnancies therefore need to come to Cairns at 36 weeks of pregnancy to await the onset of labour and the birth of their babies. All these women face the social and emotional stress associated with separation from their homes, partners and families at what is always an important time in a woman’s life.”

Queensland Rural Action Plan - June 2005

“The Premier should publicly support and ensure funding for the rural recommendations of Dr Cherrell Hirst’s Review of Maternity Services in Queensland, particularly promoting models where

• doctors support an enhanced role for midwivesexisting services are maintained
• reopening of previously closed services”

Closing Hospitals is not a new strategy

As long ago as the late seventies research into health care provision in the US focussed on national examples of problems now facing Australia in particular the Far South Coast of NSW.A report titled Hospital closure: a review of current and proposed research., S R Hernandez and A D Kaluzny, published in 1983, concluded the following...

This review of hospital closures suggests that factors contributing to hospital distress are inadequate reimbursement, inflation, management problems, organizational characteristics, and societal factors. It appears that institutions serving disadvantaged populations are more likely to close.

It is suggested that future directions for research should focus not only upon hospital cost control but also upon insuring equity in the distribution of health services. Specifically, research is needed that further describes the hospital closure phenomenon, the impact of closure, and the policy choices that might, be pursued to insure equity in continuation of health services to disadvantaged populations.

In short, these conclusions from the US identify systemic failures similar in style to the deliberate process that has enabled decision makers in NSW to target Pambula Hospital since 2005. It is reprehensible that those processes, in particular the refusal to maintain Pambula Hospital maternity services, have generated the general social and specific gender-based inequities that now exist here.

If one takes a moment to Google "closure of rural maternity units lead to poor outcomes"

...that search will provide some 2600 or more local, interstate and international scholarly articles with titles like the 100 samples shown below.Each article no doubt could help the NSW Minister for Health and his army of economic rationalist administrators in their efforts to properly manage NSW health services with best clinical practice and patient wellbeing foremost in their sights.

Evidence from all eastern states of Australia shows that closure of rural maternity units lead to poor outcomes. Read that evidence here by clicking Joint ACRRM / RDAQ submission to the Review of Maternity Services in Queensland

100 Samples of local, interstate and international scholarly articles on this subject.

Google any yellow title.

Causes and Consequences of Rural Small Hospital Closures from the Perspectives of Mayors... are at risk of closure during the ... important component of a stable rural...Quality of Care in the Rural Context: A Proposed Research Agenda... tertiary center does not mean that the rural elderly as a group will benefit from closure of rural ... If deletion of selected services in rural areas under ...Sustainable maternity services in remote and rural ... service cover and changes, threatened closure of our ... to ‘‘stand-alone’’ midwifery units in remote ... evidence of training in rural maternity care towards ...Rural Maternity Care: New Models of AccessImplementing the National Maternity Action Plan In Western Australia... already marginalised in regional and rural WA ... hospitals, some under threat of closure, have expressed ... a primary health care model of maternity services at Ryde ...Bypassing Rural Hospitals for Obstetrics CareBirth Outcomes to Rural Illinois Residents: Is There a Crisis?Does size matter? A population-based study of birth in lower volume maternity hospitals for low risk …A Prognosis for the Rural Hospital Part I: What is the Role of the Rural Hospital?Risk and childbirth in rural and remote AustraliaMaternal obesity in pregnancy: is it time for meaningful research to inform preventive and …Sustainable maternity services in remote and rural Scotland? A qualitative survey of staff views on … Policy analysis in an information-rich environmentThe Impact of Obstetrical Liability on Access to Perinatal Care in the Rural United StatesFrom little things, big things grow: a local approach to system-wide maternity services reform in …Making pregnancy safer in Australia: The importance of maternal death review... We have experienced a 10-year period with widespread closure of maternity services across rural and remote areas with little research into the ...Health care in central Asia ... and cardiology, psychiatric, neurology, maternity and emergency ... programme of rationalization of rural hospitals. ... simply reflect the unplanned closure of large ...Patterns of Obstetrical Care in Single-Hospital, Rural Counties... the availability of nearby hospitals might lead to a ... fected by the lack of obstetrical services than others ... care, Hughes and Rosenbaum noted that rural women of ...Survey of midwives, exploring the sustainability of practice as Lead Maternity Carers in one urban …Proceedings from the Invitational Meeting on Rural Surgical ServicesNeonates Northwest... neonatal intensive care can fall between maternity and paediatric ... of the particular needs of rural areas with ... the three existing lead centres, units have four ...The influence of socioeconomic and cultural factors on rural health... older generation for continued existence, the services they can ... for the health of rural communities and ... capital of associated hospital closures and reinforcing ...Impact of maternity unit closures on access to obstetrical care: The French experience between 1998 …An evaluation of the midwifery services at a New Zealand community maternity unit... stated that threats of closure were unsettling to ... for a better utilisation of primary maternity units.Multipurpose Services-A Potential Solution for Rural Health and Aged Care... felt threatened with closure or downgrading ... on multipurpose service developments ... accident and emergency services or maternity services? ...Is There a Role for the Small Rural Hospital? ... closures represent one of the major problems confronted not only by the people in the towns served by ... An Overview of Maternal and Infant Health Services in Rural America... financial barriers, or because of hospital closures-underre- porting ... Differences and trends in obstetric interventions at term among urban and rural women in New South... recently little attention had been paid to preg-nancy outcomes.1.2 In ... factors are likely to be influenced by declining rural maternity services, including a ...The North Carolina Obstetrics Access and Professional Liability Study: A Rural-Urban Analysis... the subsequent fear of being sued; closures of hospital ... disruption of the delivery of maternity care in ... A rural-urban analysis showed that differences among ...Rationalizing Rural Hospital Services In Kazakstan... in the number of buildings or closure or an ... 4, was the result of resituating all maternity and antenatal ... of pregnancy) services in one rural hospital which ...Choices, Collaboration and Outcomes in Australia... Closure of these units limits choice for the women ... The nature of Australian maternity services is currently in ... and acceptable services in the rural and remote ...Toward Really Improving the Outcome of Pregnancy: What You Can Do... applied to maternity care in many rural and a ... programs, current programs call for the closure of the ... units.* Patients in the larger maternity units may also ...Health Care Reform as an Ongoing Process... By 1970, the closure of the Booth Hospital was imminent. ... for many years under names such as maternity centers, general practitioner units, or maternity ...Paradox as invitation to act in problematic change situations... clinicians (decentralized services) and managers (centralized services). ... to achieve intellectually driven closure (as in ... of consultants in a rural hospital. ...Federal Programs Affecting Rural Perinatal Health Care... funds from state and local agencies, to operate their health department maternity and well Building the Infrastructure to Reach and Care for the Poor Trends, Obstacles and Strategies to ... hospitals, maternity homes, and children‘s hospitals with ... infrastructure standards led to closure of many rural ... even in rural areas there is substantialAdapt, Develop, Evolve, Specialise... The closure of local services and the increased ... large number of big consultant maternity units within a ... Hastings are like Whitehaven, being rural seaside towns ...A Multivariate Assessment of the Effects of Residence on Infant Mortality... low-income pregnant women receive maternity care services ... a standard defini- tion of "rural" has plagued ... measure of neonatal intensive care units utilization at ...Barriers to the utilization of maternal health care in rural Mali... and 71.0 per thousand in rural areas (CPS/MS ... on women's decision to seek maternity care include ... Intergenerational closure, which occurs when families know each ...Access to Health Care for the Rural Elderly... now operating is essential, but whether government programs merely delay closure of nonsustainable ... Access to maternity care in rural Washington: its ...Vesicovaginal fistula: obstetric causes.... because of efficient and effective maternity care systems that ... education), poor and from a rural area, and ... highly effective in terms of closure and continence ...Access to rural health services: Research as community action and policy critique... such as responses to actual or threatened hospital closures or service ... of RWNZ as a ‘watch dog’ and advocate for rural communities has ...Strategies for integrating primary health services in middle-and low-income countries at the point ... nience for the users leads to their increased satisfaction ... ambulatory care facilities, women’s health services, rural health services, vaccination and ...Rising rates of caesarean sections: Why?... and 31 per cent had come from rural areas. ... M. Trends in Caesarean section rates at a maternity hospital in ... of a single-layer or double-layer closure on uterine ...Closing rural hospitals in Saskatchewan: on the road to wellness?... offs for local businesses, the reduction in services and the ... time again, it was stated the closure of the ... affect their lives, but for many rural residents, the ...Fistulae Repairs by on the Job Trained Medical Officers in a Rural Hospital, Kagando, Western... of a series of events that lead to the ... of the defect edges followed by closure in layers. ... D. Information quality in a remote rural maternity unit in Ghana10 ...Rediscovering Appropriate Care: Maternity Traditions and Contemporary Issues in Canada... narrowed to serve those urban and rural poor without eco ... gain a legitimate footing in the maternity system is ... of health and other crucial services, usually in ...Principles and Practice of Obstetric Anaesthesia and Analgesia... He championed the cause oi obstetric anaesthesia on the ... to be so readily at hand in rural areas, yet ... and examined the luture ol maternity servicesRetaining General Practitioners in Rural Areas: Improving Outcomes Through Evidence-based ... The Victorian Universities Rural Health Consortium, The Department of Human Services Victoria and The Rural Workforce Agency ...Health Service Workforce and Health Outcomes: a Scoping Study... managing open and closed wounds in rural areas, in ... attention to the reconfiguration of maternity services away from ... the skill mix of these services, which may ...Network News... that is a recipe for the closure of both ... to do ‘their rounds’ in a remote rural area, giving ... (Maternity andpaediatric services for the South-West region ...Assessing Health And Health Care Needs In Oswestry... of the recent announcement of the temporary closure of the ... 5.7 Oswestry maternity services (page 68 ... change by profiling and assessing current services and then ...Public-Private Partnership In The Provision Of Health Care Services To The Poor In India... are in rural and tribal regions ... Municipal Corporation of Delhi (MCD) built a maternity health centre through ... any other agency this would have meant a closure of ...Canadian Journal of Midwifery Research and Practice-Revue Canadienne de la Recherche et de la ... are all too familiar in rural health: hospital closures, ... In rural places, these barriers are exacerbated ... is an acute shortage of maternity care professionals ...Executive report of the Ontario Maternity Care Expert Panel: emerging crisis, emerging solutions ... a moratorium on maternity care program closures in communities that ... Integrated MaternityCare for Rural and Remote ... our firm belief that maternity care services ...The Effects of Regionalization of Perinatal Care on Hospital Services for Normal Childbirth... of the problem of vast distances between rural towns and ... or twice the national average.28 Maternity units in that ... Most of the recent closures have been of mater ...Training and Education Needs of Emergency Medicine Doctors working in Rural and Regional Australia... problem. Rural people now not only need to travel to larger centres to access ... such as maternity care. The rising cost of health care has also seen the closure ...General Practice into the Future... Better services need to be provided in rural areas, including ... required to re-establish and develop partnerships between rural general practitioners ... Maternity ...Thank you to the following members of the New South Wales Committee: Alison Aggarwal, Centre for ... to $1.5 million, which will lead to clinic closures in metropolitan ... Maternity services need to be available and accessible to all rural women with ...The New South Wales Community Report on Women’s Human-Rights in Australia... is one of the factors that hinder people from accessing services. ... after a place or that they will cause trouble ... The rent gap also is growing in rural New South ...Advanced Case Management: Outcomes and Beyond... by the CQI approach may cause the elusiveness ... rose 29% and mental health services increased by ... 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Report of the Review of the Bega Valley Maternity Services

This report has put aside the evidence contained in the Joint ACRRM / RDAQ submission to the Review of Maternity Services in Queensland (provided above) in favour of their own more parochial views.

Read the full report

NSW Health Department, Greater Southern Area Health Service

Bega Valley Maternity Review Report

Read the full report

Greater Southern Area Health Service has announced that it will adopt the recommendations of the Review of the Bega Valley Maternity Services Report

The Review of Bega Valley Maternity Services report summarised its findings as follows:

Executive Summary

For some years the Bega Valley has had considerable difficulty in sustaining maternity services in both Bega and Pambula. The distance between the two towns is 33 kms, with a travelling time of between 20 and 25 minutes. Since January 2007, efforts have been made to maintain both units, initially through alternating weekends and, since November 2007, alternating weeks in which each unit is open.A single maternity service will operate when the new Bega Valley Health Service, which will replace both Bega and Pambula Hospitals, is completed. Construction has been approved, with an anticipated completion date of 2012. There remains some dissatisfaction in the southern part of the Shire that the preferred site is close to Bega.The current arrangements are not only a source of considerable distress to the community, but also may be contributing to a diminution in the standard of service. Mothers are unhappy with the lack of certainty of the hospital in which they will be confined. Some are electing to have early intervention to eliminate the uncertainty, and many are choosing early discharge to avoid the need for transfer to the alternate hospital in the post-natal period.Providing a safe service for mothers and babies has been the primary consideration of the Review Team. In the interests of safety, we believe that a single service operating from Bega should be implemented as soon as possible. We make this recommendation after giving due consideration to the fact that that it may contribute to the loss of services from procedurally competent general practitioners at a time when considerable effort is being devoted to maintaining and expanding the role of such general practitioners and of maintaining maternity services in rural Australia.We have concerns that a single service will not be viable unless additional support is available to allow the Bega general practitioner obstetricians to maintain a safe and sustainable after-hours roster. We have identified a number of options that can be explored to achieve this sustainability, but recognise that it will require considerable effort and additional resources.We believe that there will be a need for strong midwifery leadership in the single site, to assist with upskilling of staff, ensure consistency of advice and oversee the development of choices in models of care.We believe that a unit with over 250 births per annum will enable mothers to have greater choice in relation to model of care, will assist in the recruitment of midwives and hopefully general practitioner obstetricians, and will reduce the risks associated with the current model.We note that there are some areas of concern that are unrelated to the location of the service, and believe that these should be addressed as far as possible within the existing facilities.

Recommendations

1. All obstetric services should operate from a single site at Bega Hospital

2. A senior specialist or general practitioner obstetrician should be engaged for a period of three months to oversee implementation of the changes

3. Additional medical practitioners should be recruited, aiming to achieve a 1:6 afterhours roster for Bega medical practitioners, but with a minimum of 1:4

4. A new position of Clinical Midwifery Consultant should be established for the Eastern Sector, with the initial responsibility directed towards implementing the above changes

5. A program of education and upskilling for midwives should be implemented

6. The maternity service should be adequately staffed, with one midwife and a second appropriately trained nurse at all times dedicated to the service

7. Pambula midwives should be consulted individually to identify and, if possible, overcome, barriers to their relocation to Bega

8. Beds should be dedicated to the obstetric service, with the three delivery suites used only for delivery, and dedicated post-natal

. Antenatal and post-natal care should be provided from multiple sites across the area

10. The post-natal outreach service should be expanded to ensure access for all mothers

11. A mechanism to ensure a strong clinician and consumer voice in the planning of maternity facilities in the new hospital should be identified, either as a separate Maternity Advisory Group or a subgroup of the Bega Valley Health Advisory Council.
This group should also monitor progress of and satisfaction with implementation of the recommendations of this report

12. Issues of concern such as privacy, a partner- and family-friendly service and quality of food, should be addressed

13. The Bega Valley should not attempt to recruit a permanent solo specialist obstetrician and gynaecologist, but should maintain a close relationship with obstetricians at the Canberra Hospital.

Thursday 9 October 2008 - ABC News

Rural hospital to scrap maternity services

Ken Barnett from the health service says the move will allow obstetrics at Bega to be improved. "It will help us provide a safe and sustainable service into the future. It will allow us to improve the quality of service that we provide," he said.

Read what else he said

Editor - Contrary to Ken Barnett's views the Joint ACRRM / RDAQ submission to the Review of Maternity Services in Queensland concluded that, "Small rural obstetric units need to be supported and re-established as the safest delivery option for rural women. When they are closed, the associated social and economic effects lead directly to quantifiable increases in perinatal mortality."