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Expert Group on Acute Maternity Services: Reference Report

ANNEX C: International Models of Maternity Care

Examples of Care Provision Worldwide

Drawing comparisons from international models of maternity care can be problematic but it is a useful comparator if only to prompt debate. The countries identified are just a random sample of models of maternity care and are intended as to illustrate the issues surrounding the provision of maternity care.

Sweden

Sweden has a population of almost nine million and an average of 90,000 births annually. It has a national health service, which provides all elements of maternity care. Most care is provided by the midwife. The midwife refers to an obstetrician when necessary, although two visits to the obstetrician are factored into routine antenatal care. Very few GPs are involved in maternity care. Sweden has two birth centres, but elsewhere the midwife is the lead professional for low risk women. 99% of women receive their maternity care via a highly co-ordinated system of clinics for antenatal and postnatal care (mothercare centres) and hospital. For this reason continuity of care is not usual in Sweden, as midwives who work in the clinics do not work in hospitals. The vast majority of births take place in hospital (99%) and home births are rare. The infant mortality rate is the third lowest in developed countries (behind Finland and Japan). Much of the emphasis is placed on social issues and multidisciplinary team work. There is a general shortage of obstetricians. The caesarean section rate in 1998 was 13.4% and breastfeeding rates are very high.

Finland

Finland has a population of 5.1 million and an average of 56, 700 births annually. Finland is divided into 452 municipalities and has 21 hospital districts with responsibility for proving and co-ordinating care in that district. Maternity care is provided by a variety of professionals (midwife, public health nurse, GP and gynaecologist). Municipalities can employ midwives and public health nurses to provide ante- and postnatal care (over 60% do not employ midwives). Most of the antenatal care is provided by the midwife or public health nurse in community based clinics. The service is not integrated and these staff will not be involved with intrapartum care in hospital. There is quite an intensive antenatal care regime even for low risk women, who are cared for locally until referral to the hospital for intrapartum care. Although midwives are responsible for caring for low risk women, this is under the supervision of the gynaecologist. Outcomes are good, mortality and morbidity rates are very low and breastfeeding rates are high.

Ireland

Ireland has a population of 3.5 million and approximately 55, 000 babies are born annually. Over 40% of these babies are born in one of the three maternity units in Dublin. Health boards provide free maternity services for all expectant mothers for the period of the pregnancy and for 6 weeks after the birth. This service is provided by the GP in combination with a maternity unit or hospital. Most women, and especially private patients, choose the obstetrician to be their primary care provider and midwives tend to be hospital based. The majority of births take place in hospital (99.6%). National outcome statistics are difficult to obtain, but breastfeeding rates are very poor. There is one private birthcentre in Dublin and currently there are plans to open Ireland’s first public CMU in Dublin. Unlike in the UK, midwives do not need to register an intention to practice annually, thus making it difficult to establish how many midwives are actually practising at any time. There is a medical, nursing and midwifery manpower crisis in Ireland and many professionals are being recruited from abroad.

Netherlands

The Netherlands has a population of 16 million and approximately 200,000 babies are born each year. It is a relatively small and densely populated country: population per square kilometre is 351 compared with the UK where it is 233 (Mander, 1995). It has a dual health insurance scheme - a public one for people below a certain income and a private system for those who do not qualify for the former. The focus of maternity care in The Netherlands is ‘normality’ and the care is based on ‘graded’ risk assessment. For low risk women the midwife or GP are the first and only point of professional contact throughout pregnancy, collaborative working and clear guidelines exist. Professionals seem to work well together. The culture and demographics are different to the UK and midwives must be within 20 minutes of a woman who has requested a home birth. The home birth rate is high (33%) and the majority of low risk women deliver in midwifery units. Because of the way in which maternity care is funded, women are discharged within 24 hours and midwives do not provide postnatal care. Those who are insured can pay for a maternity care assistant to provide support in the postnatal period.

Norway

Norway has a population of 4.5 million, on average 60,000 births per year and 60 maternity units. The state health scheme provides free maternity care for all women and is used by over 99% of women. Geographically, Norway covers an area equivalent to approximately half of France, but 25% of its population live in or near Oslo. It is divided into five health regions, each with one tertiary referral centre. Within each region there are several small local hospitals and maternity homes (small maternity units run by midwives without hospital facilities or supervision by other than the local GP). Most of the care for low risk women is midwifery led, and there is close partnership with GPs and obstetricians. Women are expected to choose the geographically nearest maternity unit where appropriate. The home birth rate LOW (<0.5%), intervention rates are approximately 25% (caesarean section and instrumental delivery) and breastfeeding rates are over 99%.

USA

The funding of maternity services in the USA is via ‘Medicaid’, which is a partnership between the federal government and participating state governments. States given authority to set reimbursement rates for health provide nurse/midwives who treat Medicaid patients. Legislation varies from state to state and there are lay midwives and, in some States, certified nurse/midwives. Birth centres and birth ‘farms’ are becoming a popular option for women and these vary in size and manpower. Generally, maternity care is obstetric led and there is a high uptake of private obstetric care, only 6.5% of births managed by a certified nurse/midwife (National Centre for Health Statistics, 1998). Intervention rates are high, with a caesarean section rate of 23% in 2000, but other outcome figures are difficult to establish.

Australia

The Federal Department of Health & Ageing funds the State based health services. ‘Medicare’ is health insurance for all, funded from a Commonwealth Government tax on all salaries. How hospitals allocate maternity funds is up to the individual hospital. Once pregnancy is confirmed, the woman can choose who she attends for maternity care. This can be a midwife or be based on a shared care model (similar to UK). If the woman opts for private maternity care, all antenatal care will be provided by the obstetrician and she may not see a midwife until she is admitted in labour, but even then it is the obstetrician who will carry out the delivery. In 1999, there were 257,394 babies born to 253,352 mothers which were notified to perinatal data collections in the States and Territories, a 0.7% increase in the number of births compared with 1998. This represents a birth every 2 minutes, with approximately 705 births per day in Australia in 1999. In 1999, more than 1 in 5 (21.9%) births were by caesarean section. South Australia (24.9%) had the highest caesarean rate in 1999 and the Australian Capital Territory (19.6%) the lowest. Caesarean rates were higher among older mothers, those having their first baby and those who were private patients. Mothers without private health insurance had shorter postnatal stays than those with private health insurance. Manpower and demographic problems have resulted in a drive to enhance midwifery care for low risk women.

Canada

Maternity services are covered in Canada by a Canadian Public Health System, each state having a health insurance plan. Traditionally, maternity services were obstetrically led and intrapartum care was supported by obstetric nurses. Obstetricians have a regional approach to maternity care and until recently midwives were not recognised in Canada. Some states now have registered midwives but the numbers are few - in Ontario in 2001 only 3% of deliveries were by a midwife - and intervention rates are high. However, manpower problems exist: there is a difficulty in recruiting obstetric staff and, as midwifery is relatively new, there are deficits in staffing in this field. One suggestion by a large Canadian University is to develop courses for Acute Care Nurse Practitioners (Maternity Care) educated to Masters level. It is anticipated that these professionals will be able to fill some of the existing maternity manpower gaps.

New Zealand

The past decade has seen changes in legislation and in how maternity care is provided in New Zealand. The National Health Service funds all elements of maternity care, although there is some obstetric managed private care. In 1990, a change in the law brought about a system whereby pregnant women can choose a midwife, a GP or an obstetrician to lead her maternity care. All women must have access to a maternity care facility which, in conjunction with the midwife, provides inpatient services during labour and birth and in the immediate postnatal period until discharge home. A professional consensus by all disciplines on referral guidelines has been agreed. There are many birth centres for low risk women and breastfeeding rates are high (approximately 80%).

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