The failure to foresee the baby boom that began in Australia in 2005 and has now hit a thirty-year high has had serious consequences for public hospitals and birthing services. Its impact has been felt more severely because of shortages in the maternity workforce. A workforce survey conducted in 2003, before the onset of the baby boom, by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, predicted that increasing retirements, falling doctor numbers due to the cost of medical indemnity and the impact of practice on lifestyle, and a feminisation of the workforce would all contribute to serious shortages of experienced practising obstetricians in the near future.

There are also shortages of midwives right across Australia and their practice is currently restricted by the cost of indemnity insurance and the fact that they cannot gain access to the Medical Benefits Scheme unless they work under medical supervision.

Steady increases in the average maternal age, higher rates of multiple births and growth in the number of pregnancies resulting from assisted reproduction technologies have made maternity care in Australia increasingly complex. As a consequence of these factors and others, pregnancy and birth has increasingly involved sophisticated medical interventions, reflected in the dramatic increase in caesarean rates.

Many of the challenges for maternity services in Australia are outlined in the report 'Improving Maternity Services in Australia,' released last weekend. In a recent discussion paper we have outlined a framework for improving the standard of maternity services in Australia, focusing specifically on risk management and better integration of care during pregnancy and birth because these two critical issues are amenable to change in the short-term. The paper outlines a framework for service provision by detailing three clinical pathways for maternity care - one each for low, moderate and high-risk mothers and/or babies. It is not designed to be a “one size fits all” solution: it needs to be modified to suit conditions in each state and territory, and different regions within them. It will also need to be modified over time, as existing problems, such as workforce shortages and the lack of maternity units in many rural areas, are gradually resolved.

The framework does, however, provide the basis for developing more integrated, more efficient, and safer maternity services in Australia. To implement the framework, it will be necessary to develop clear, consistent, mandatory protocols for consultation and referral between health professionals, alongside the introduction of integrated clinical networks for maternity care in each state and territory.

In an environment where there is a lack of trust, and sometimes even hostilities, between health professionals, relying on voluntary guidelines for referral and consultation between these professionals is inadequate. To ensure the highest quality of in maternity care in Australia, it is vital that procedures for risk assessment and management are clear, accepted and recognised nationally, and mandatory for all health professionals working in obstetrics. The negotiations required to reach this point will undoubtedly be extremely difficult. It is critically important for patient safety, however, that these protracted demarcation disputes over health professionals’ roles give way to integrated services that focus on the needs of the pregnant woman and the best outcomes for her and her baby.