Victorian Auditor-General’s report
12 October 2011
 
Maternity Services: Capacity
Audit summary
Background 
Healthy outcomes for women and their babies are dependent on adequately resourced maternity facilities and an appropriately skilled workforce. Maternity services are a core part of healthcare delivery, representing 5 per cent of all public hospital admissions and 17 per cent of state-funded hospital outpatient appointments. Responsibility for the delivery of antenatal care, or care during pregnancy, is shared between the Victorian Department of Health and the Commonwealth. 
Pressure on maternity services has increased over the past decade. After a number of years of decline, birth rates started increasing in Victoria from 2001. This growth peaked during 2007–08, with the highest number of births since 1971. Rising numbers of women experiencing complex pregnancies due to increasing risk factors, such as age and obesity, are also placing greater demand on maternity services. 
The department undertakes statewide planning for maternity services while health services plan locally to meet the needs of their communities. 
The department is responsible for:
·	monitoring demand and supply of maternity services
·	developing policies and strategies to guide the provision of maternity service
·	working with health services through capital and service planning to support the equitable distribution of resources.  
The 2004 policy document, Future Directions for Victoria’s Maternity Services, set out a framework for strategic changes to maternity services over a 5–10 year period. The policy focused on:
·	providing maternity services for women with uncomplicated pregnancies in local settings, with appropriate access to tertiary care which deals with the most complex pregnancies, deliveries and newborns, if required
·	providing women with greater control of their birthing experience 
·	promoting continuity of care by the same midwife or small group of midwives. 
Health services are responsible for delivering services that meet the needs of their community in collaboration with the department. This includes local planning activities such as:
·	predicting local demand and assessing service use patterns
·	understanding community demographics and tailoring services to need
·	assessing current and future capacity and identifying gaps
·	developing local workforce strategies
·	coordinating with other health services in the area. 
The audit examined whether the department and health services effectively plan to meet current and future demand. It also examined whether women throughout the state can access the services they need at the optimal time.
Conclusions
Planning is critical to the delivery of effective, accessible maternity services. However, shortcomings in the department’s planning approach have limited its understanding of maternity capacity in Victoria. Therefore, it cannot demonstrate that maternity services are provided when and where needed. The department:
·	does not use individual health service plans to inform a system-wide view of maternity services
·	has only recently undertaken to map maternity services across the state
·	has limited data about the timeliness of access to antenatal services 
·	has not accessed external advice to inform strategic planning. 
As a result, the department’s planning decisions are not based on system-level knowledge of maternity service capacity. More positively, the department is now beginning to gather information on the maternity system which will allow it to reliably identify gaps in service delivery. It will be important that the department then sets out actions to address any issues identified.
Access to maternity services for antenatal, labour/birth and postnatal care is not equitable. This relates to a number of factors including a lack of state-level planning of maternity services, different approaches by health services in delivering care, and variable access to Commonwealth services through general practitioners. In particular, women at audited hospitals in metropolitan growth areas face increased costs and delays in accessing antenatal appointments due to fewer publicly available services.
Findings
Planning for maternity services
Planning for maternity services is essential as it is a basic healthcare need. To plan effectively, the department needs a thorough understanding of the system-wide demand for, and supply of, maternity services. A sound evidence base to inform this understanding is critical. 
The department works with health services when preparing health service plans to assure consistency with statewide strategic and policy directions for maternity services at the local level. However, it was unable to demonstrate that it uses these service plans to form a system-wide view of maternity services and identify gaps. Until very recently, the department had not undertaken an assessment of the capacity of health services to deliver maternity services. It also lacks a formal avenue to obtain external advice on system-wide maternity planning issues. As a result, it cannot be assured that maternity services are provided when and where needed.
Improvements to the department’s planning approach are underway to address these limitations:  
·	In 2011, the department released the Capability Framework for Victorian Maternity and Newborn Services. Health services use this to assess their maternity capacity and capability and report the results to the department. At the time of the audit all health services had submitted their self-assessments to the department. 
·	The establishment of an external advisory committee to consider both maternity and neonatal strategic planning issues was proposed in June 2011.
·	In April 2011, the department conducted a census of maternity and labour ward beds to improve its understanding of statewide capacity. 
·	There have been a number of improvements to the demand forecasting model to improve reliability.  
These are important inputs to planning and will assist the department to identify shortfalls and inform future service and capital planning.  
At the local level, audited health services have an informed understanding of their demand and a sound evidence base for planning. A number of collaborative projects and arrangements using new models of care are in place to maintain or enhance maternity services. 
All health services had experienced challenges in recruiting and retaining a maternity workforce but strategies such as promoting staff wellbeing and professional development, and introducing flexible working arrangements, are effectively addressing these shortages. 
Access to maternity services 
All services have developed a range of strategies to manage demand. The use of outreach clinics in the community is increasing timely access for women close to where they live, while maintaining access to hospital-based services for women with more complex medical needs.
To manage demand, and support access for women most in need, tertiary hospitals limit the intake of women with low-risk pregnancies who are outside their catchment area. While this appropriately targets tertiary services to local and high-risk women, the lack of structured acknowledgement and communication by the department about this approach has led to confusion among women about where they can access services.
At the audited health services in metropolitan growth areas we found that women experience poorer access to services, including higher fees and delays in antenatal appointments. In one region of Melbourne, women who are unable to access public antenatal care at their local service must pay several thousand dollars for their care or travel to another health service. 
To improve maternity services, the department needs to know whether access is timely and equitable, but it has not routinely collected information about access to antenatal services. The department is improving its data collection, and health services are now required to report the number of weeks gestation at a woman’s first antenatal visit as an indicator of timeliness of access. 
Access to woman-centred care 
Consultation with stakeholders and service providers revealed a widely held view that the maternity ‘system' is not well understood by women and some general practitioners. 
The department’s website Having a Baby in Victoria explains different levels and models of maternity care, however, the information is not well organised and is not available in a printed format or in languages other than English. The audited hospitals gave women information on a range of pregnancy care topics, but the availability of this information in languages other than English varied. 
To facilitate choice and help support informed decision-making, comprehensive information in a range of languages must be accessible to all women. 
Continuity of care refers to women having the same caregiver or a small group of caregivers during their pregnancy, labour and birth, and postnatally. Continuity of care is a key principle of Future Directions for Victoria’s Maternity Services. To improve continuity, three of the audited hospitals offer ‘Midwifery Group Practice’ where a primary midwife provides maternity care during pregnancy, birth and postnatally. However, women have limited access to this model because demand outweighs available places. 
Health services do not routinely monitor or report on their progress in improving continuity of care. An annual survey of public hospital patients shows that, while health services have made some progress since the policy was released in 2004, less than half of the women surveyed experienced continuity of care. This survey relies on consumer response and is not as rigorous as requiring health services to routinely report progress against this policy objective. 
All audited hospitals had responded to the needs of their local communities by establishing targeted programs for women from specific groups, such as a dedicated maternity clinic for Aboriginal women or women with an Aboriginal partner. However, audited health services are not evaluating these programs robustly and cannot assess whether they are improving care.
Recommendations
Number	Recommendation	Page	
1.	That the Department of Health improve its understanding and planning of maternity services by:
·	routinely measuring and monitoring maternity service capacity
·	documenting a work plan for the Capability Framework for Victorian Maternity and Newborn Services which clearly articulates how it will address gaps and issues identified
·	establishing an advisory committee with external health sector and consumer representatives to provide strategic system-wide planning advice.	22	
2.	That the Department of Health focuses on improving access to maternity services in growth areas.	34	
3.	That the Department of Health prioritises its work with the Commonwealth to improve access to antenatal care.	34	
4.	That the Department of Health provides information in relevant community languages, made available through general practitioners and hospitals, that informs women on how to navigate the maternity system, the range of maternity services options and likely costs.	42	
5.	That the Department of Health requires health services to monitor and report their progress in improving continuity of care on an ongoing basis.	42	
6.	That health services systematically evaluate targeted programs for vulnerable women to assess whether they are meeting objectives.	42	

Submissions and comments received
In addition to progressive engagement during the course of the audit, in accordance with section 16(3) of the Audit Act 1994 a copy of this report was provided to audited health services and the Department of Health with a request for submissions or comments.
Agency views have been considered in reaching our audit conclusions and are represented to the extent relevant and warranted in preparing this report. Their full section 16(3) submissions and comments, however, are included in Appendix A.