rFamily and Community Development Committee

14 July 2017

The Executive Officer Family and Community Development Committee Parliament House, Spring Street EAST MELBOURNE VIC 3002

By Email: [email protected]

Dear Family and Community Development Committee

Re: Inquiry into Perinatal Services – RANZCOG submission The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) are pleased to provide the following submission to the Victorian Parliamentary Inquiry into Perinatal Services. I would be very happy to be contacted to clarify any part of the submission. I can be contacted at:

Professor Steve Robson, President Royal Australian and New Zealand College of Obstetricians and Gynaecologists College House 254-260 Albert Street, East Melbourne, Victoria 3002 t: +61 3 9417 1699

Yours sincerely

Steve Robson

President

encl

COLLEGE HOUSE 254–260 Albert Street, East Melbourne, VIC 3002, Australia | ABN 34 100 268 969 TEL: + 61 3 9417 1699 | FAX: +61 3 9419 0672 | EMAIL: [email protected] | WEB: www.ranzcog.edu.au

Professor Steve Robson President

mailto:[email protected]

mailto:[email protected]

http://www.ranzcog.edu.au/

hrosssod

Typewritten Text

Submission S035 Received 14/07/2017 Family and Community Development Committee

Response from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists |June 2017 Page 1 of 9 RANZCOG Response to the Parliament of Victoria - Inquiry into Perinatal Services

Parliament of Victoria

RANZCOG Response to the

Victorian Parliamentary Inquiry

Into Perinatal Services

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) welcomes the opportunity to provide this submission to the Family and Community Development Committee, leading the Victorian Parliamentary Inquiry in Perinatal Services in Victoria.

Background

The purpose of the Inquiry is to consider and report on the current situation relating to the health, care and wellbeing of mothers and babies in Victoria during the perinatal period. This submission is structured according to the 7 categories in the terms of reference for this inquiry.

1. The availability, quality and safety of health services delivering services to women and their babies during the perinatal period

Recommendations:

a. The principle of “Informed Choice for Women” should guide choices in maternity care

Rationale:

Choices in maternity care have historically been made on behalf of women, rather than by women. RANZCOG believes that women should be offered information on the full range of options available to them throughout pregnancy, birth and the postnatal period. This information should include the models of care available locally, screening tests available during pregnancy, and information about birth and postnatal care.(1) The importance of providing informed care regarding mode of delivery has been highlighted in a very important recent judgement in the United Kingdom in 2015 (Montgomery v. Lanarkshire Health Board). In this case, a woman was not given an option of elective caesarean section for a macrosomic diabetic pregnancy. In summing up, the justice stated: “Whatever Dr McLellan may have had in mind, this does not look like a purely medical judgment. It looks like she judged that vaginal delivery is in some way morally preferable to a caesarean section: so much so that it justifies depriving the pregnant woman of the information needed for her to make a free choice in the matter.”(2) It is now accepted that women show considerable diversity in their choices around childbirth(3) and such diversity should be respected while providing information free of prejudice or bias.


b. A “Collaborative Model” of maternity care is prioritised

Rationale:

Collaborative maternity care is designed to promote the active participation of different health disciplines in providing quality care that is tailored to meet an individual woman’s needs prior to, during and after pregnancy. RANZCOG endorses a collaborative model of care for all women, irrespective of their risk profile. A high risk-low risk dichotomy tends to support division of craft groups, creating barriers for women whose risk profile may change during pregnancy, labour or the postnatal period. RANZCOG recognises that outcomes in pregnancy are optimised where there is clear collaboration and easy access to both midwifery and medical expertise in all-risk pregnancies. Whilst some midwifery led-care models of care are promoted as being superior, evidence has emerged of a small increase in perinatal mortality and morbidity with midwifery-led care in comparison to a traditional model of collaborative care between both obstetricians and midwives – despite the latter group having patients with a higher risk profile.(4) The collaborative model creates an environment of trust and respect in the workplace, thus enabling a culture which prioritises patient safety.

c. The provision of Genetic Services should be reviewed incorporating consultation with key stakeholders – particularly Maternal Fetal Medicine Units

Rationale:

Current resourcing of Prenatal Genetics is inadequate, both in terms of salaries and testing budgets. The number and range of genetic and chromosomal conditions detectable in the prenatal period is increasing due to advancing genomic technologies. We are now detecting twice as many major chromosome abnormalities per year compared with 20 years ago (approximately 400 per year in VIC since 2013). Greater resourcing is required to ensure a skilled prenatal genetics workforce, and to support informed decision-making for families. Moreover, there is an urgent need to address the inequity in access to genetic services across the state. The consultation draft of the Australian National Health Genomics Policy Framework clearly states that the health benefits of genomic knowledge should be harnessed in an “efficient, effective and equitable way”. State-wide geomapping of prenatal diagnostic practices have identified substantial variation in indications for invasive testing according to socioeconomic status, suggesting that the benefits of the new screening tests such as non-invasive prenatal testing (NIPT) are unevenly distributed. Utilisation of advanced screening tests such as NIPT has been limited by its high direct patient cost, and so socioeconomically disadvantaged women are disproportionately relying on inferior forms of screening (such as second trimester serum screening) that have higher rates of false positive results. This leads to higher rates of unnecessary invasive procedures (with inherent risks of iatrogenic fetal losses) being shouldered by those at greatest socio-economic disadvantage. Increased consumer demand in the area of prenatal diagnosis as well as the rapidly evolving science of genomic medicine, means the need for clinical service providers is expanding, and there is an imperative for ethical and informed debate to inform public health policy. Existing Perinatal Medicine services at the tertiary hospitals are well placed to provide these services and contribute to prenatal diagnosis policy, but meeting the clinical needs of Victorian women requires better resourcing with Genetic Counsellors and Medical Geneticists. Challenges in meeting prenatal testing expectations are likely to increase given the inadequacy of the testing budget allocation. The capacity of prenatal genetics services to inform and direct the genomic framework in public policy is limited because of non-membership with the Melbourne Genomics Health Alliance.


d. All women are entitled to a comprehensive Family Planning Service as a component of their maternity care and therefore:

i) A hospital-based comprehensive Family Planning Service must be established at Werribee Hospital

Rationale:

A comprehensive (including hospital-based) Family Planning Service is fundamental to the delivery of contemporary women’s health care. All women in Victoria should have equitable access to reproductive planning services, including contraception and termination of pregnancy. Access to reproductive planning services should be on the basis of health care need and should not be limited by age, socioeconomic disadvantage, or geographic isolation. Equitable access to services should be overseen and supported by health departments in each jurisdiction in the same way it is for other health services. There are many areas, particularly in regional Victoria where access is limited. Even in metropolitan Melbourne women in the region of Werribee Mercy Hospital have no reliable access to local reproductive planning services. RANZCOG supports moves toward a Victorian sexual and reproductive health strategy, which would have the potential to support the following dimensions of sexual and reproductive health care;

Education and the development of health literacy including access to and uptake of contraception.

Equitable access to optimal sexual and reproductive health services, including termination services.

Monitoring and research. Workforce development and succession planning.

ii) The Austin Family Planning Service must be maintained within the Austin Hospital (including termination of pregnancy services) and clear lines of referral are required for women in need of second trimester termination of pregnancy (based on the geographical location of their place of residence).

Rationale:

The Mercy Hospital for Women has an established Maternal Fetal Medicine Unit appropriate for a tertiary facility. As the Hospital does not provide Termination of Pregnancy Services, women in need of these services need to be able to access them in a timely and geographically appropriate manner. The Austin Hospital has provided a Family Planning Service since the Mercy moved to the site in May 2015 but periodically reduces the service and on occasions threatens closure of the service. It is essential that this service is maintained for the women of the North-East at the same or increased levels.


2. The impact that the loss of Commonwealth funding (in particular, the National Perinatal Depression Initiative) will have on Victorian hospitals and medical facilities as well as on the health and wellbeing of Victorian families

Recommendations:

a. Maternal Social and Psychological Health should be given priority in the delivery of maternity care, both antenatally and postnatally

Rationale:

The importance of perinatal mental health and well-being cannot be underestimated in ensuring the future health of the next generation. Perinatal anxiety and depression arises from a complex interplay of biological, sociological and psychological factors occurring at this time and can affect mothers and fathers. Risk factors include a history of mental health problems, lack of social supports, previous trauma including physical, emotional or sexual abuse, isolation (physical, mental, cultural), stressful life events, and a history of drug or alcohol abuse. Suicide has become one of the leading causes of maternal deaths in Australia. The presence of maternal mental health conditions can also have an adverse impact on the growth and development of the fetus/infant, and the wellbeing of other family members. The psychological wellbeing of pregnant women and new mothers should therefore be considered as important as their physical health and considered as part of routine antenatal and postnatal care. Recognition and management of postnatal depression requires a comprehensive plan to address the complete spectrum of maternal social and psychological health, which would include not only depression but also other key issues such as domestic violence, drug & alcohol dependence and economic disadvantage.

3. The adequacy of the number, location, distribution, quality and safety of health services capable of dealing with high-risk and premature births in Victoria

Recommendations:

a. Prioritising perinatal care in Victoria means ensuring that Neonatal Intensive Care and Special Care nursery capacity is urgently addressed.

Rationale:

There is a continuing serious shortage of maternal and neonatal beds at hospitals equipped with a Neonatal Intensive Care Unit such that women are unable to be transferred when there is an indication to do so. This puts undue pressure on the PIPER consultant to recommend that a patient remain in a rural or outer urban centre not equipped to manage problems should they occur. All Melbourne units, especially perinatal units, are running well above their normal rated ICU/Ventilator capacity most of the time. Units are often operating above capacity with no increase in space, equipment, staff or infrastructure. When a baby is admitted under such circumstances the risks to that baby are significantly greater, but the admission of that baby also increases the risk that other babies will die or suffer complications. Our capacity to manage the system safely and effectively has been significantly compromised by the recent decision to close the VICPIC site, used for monitoring NICU and Obstetric capacity and to shift to the REACH website used for other ICU services in Victoria. This website does not contain information about Maternity bedstate, which impairs our capacity to determine where to send a high risk mother (who may herself be at significant medical risk) while trying to keep her close to her baby and to avoid overloading any particular perinatal unit.


b. Plans for the fifth NICU to be built at Western Hospital Sunshine should be progressed expeditiously.

Rationale:

i) Western Hospital Sunshine is geographically suited for timely access of patients requiring tertiary care in the Western section of Victoria. RWH is placed for the North, Mercy the North-East and Monash the East. Already the Victorian Regional Mortality initiative has established these geographical groups with Western leadership providing direction for both Geelong and the Western District. ii) Western Hospital Sunshine has the volume of both Obstetrics and Gynaecology to become a full-training hospital for Obstetricians & Gynaecologists. Despite its large number of births and particularly good gynaecology training, the absence of a NICU at Sunshine currently prevents the hospital becoming a comprehensive centre for O&G training. Although training in each of obstetrics and gynaecology can occur at different locations, this is far from ideal from service delivery perspective where “safe working hours” mean that those undertaking gynaecology rotations will usually need to participate in the emergency obstetric on-call roster.

c. Considerations regarding requirements of high risk patients in the North of Melbourne need to be considered with the expansion and development of services at the Northern Hospital

Melbourne’s Northern corridor has experience significant growth over the last 10 years, with the population set to significantly increase with the development of Kalkallo (35km north of Melbourne’s CBD) into the new suburb Cloverton. The 1141ha Cloverton site is set to house 30,000 people over the next 30 years. To put this growth into perspective, the Cloverton city centre will be the same size as Melbourne’s CBD and if you were to overlay Cloverton on a map of Melbourne it would stretch from Albert Park in the south to Brunswick in the north. Construction has already commenced on this new community, which is set to have eight schools, a tertiary institution, parklands and a retirement village yet there are no plans for a new hospital or increasing capacity in nearby facilities. The closest public hospital is the Northern Hospital (17km) followed by the Austin/Mercy Hospital (37kms) and then Royal Melbourne Hospital (43kms). There is a clear need to resource health services which will be impacted by this population growth.

4. The quality, safety and effectiveness of current methods to reduce the incidence of maternal and infant mortality and premature births

Recommendations:

a. The current set of Victorian Maternity Performance Indicators should be maintained and strengthened with the correction of some obvious anomalies

Rationale:

These indicators are a great strength of the Victorian maternity service and credit is due to those responsible. One anomaly that requires correction is the issue of Maternity Clinical Indicator 3 – Detection of Fetal Growth Restriction. The indicator is currently not customised for maternal height and weight. This will mislead clinicians in performance assessment if their population has a higher or lower incidence of obesity than other centres. There is very good evidence that customisation by height and weight better predicts the fetus at risk than uncustomised birthweight centiles.(5, 6) Compliance with immunisation should be considered as a new Maternity Performance Indicator to increase uptake of influenza and pertussis vaccination in pregnant women, both shown to reduce the risk of major maternal and perinatal morbidity and mortality.


b. Reporting of Congenital Anomalies must be improved

Rationale:

A review of the Congenital Anomalies Reports from 2007-09 and 2013-14 suggests massive underreporting of chromosome anomalies in the 2013-14 document - about half of the actual prevalence as ascertained through the Murdoch Children’s Research Institute Victorian Prenatal Diagnosis data collection. This is because laboratory and clinical reporting of congenital anomalies to the Victorian Perinatal data collection is not mandatory (e.g. only 1 cytogenetic report in 2013-14, compared with 1407 reports in 2007-09). Ascertainment of structural congenital anomalies detected by ultrasound is also unreliable due to the reliance on voluntary reporting, and the lack of state-wide data collection on terminations for fetal anomalies prior to 20 weeks gestation across the public and the private sectors. The Australian response to the Zika virus epidemic highlighted the inadequacies of our state birth defects monitoring system, both in the timeliness of reporting (the VIC 2007-09 Congenital Anomaly Report was only published this year), and its incompleteness due to the reliance on voluntary reporting. The accuracy of the congenital anomaly reports is vital for assessing the performance of Victoria’s prenatal screening program and obstetric ultrasound services, and to allow early detection of future emerging birth defect epidemics. State-wide data collection on structural and genetic anomalies can be improved with support for reporting anomalies from laboratories, maternity and paediatric clinical and diagnostic services, and facilitating record linkage between obstetric and newborn population datasets.

5. Access to and provision of an appropriately qualified workforce, including midwives, paediatricians, obstetricians, general practitioners, anaesthetists, maternal and child health nurses, mental health practitioners and lactation consultants across Victoria

The single most important issue in the medical workforce is the maldistribution away from rural centres. Known strategies are available (see below) but inexplicably have not been utilised at State and Commonwealth levels.

Recommendations:

a. Through the AHMAC, the Victorian and other Health Departments should put strategies in place to address the maldistribution of the health workforce including that AHMAC:

i. Mandate (as a condition of Commonwealth Funding) that medical schools have at least 35% of their medical school intake from a rural (secondary schooling) background

Rationale:

Deans have been very successful in gaining funding for rural clinical schools. These are known to be of limited value in encouraging future rural practice. Overwhelming, established to be more successful is to set intake quotas of students from rural background.(7, 8) These currently stand at 25-30% and must be increased.

ii. Mandate (via the addition of a new AMC Standard in the Australian Medical Council accreditation of the Medical College Specialist Training Programs) that the Medical Colleges have strategies in place in selection of trainees and their training that will enhance the specialist rural workforce

Rationale:

There is currently no AMC Standard that directly addresses this critical issue in Specialist Medical Education. This is easily remedied but requires AHMAC to direct the AMC to address this deficiency in the AMC Specialist Medical College Accreditation Standards.


6. Disparity in outcomes between rural and regional and metropolitan locations

Recommendation:

a. The “PIPER” process for maternal and neonatal transfer should be urgently reviewed

Rationale:

While there have been clear benefits to both referring and receiving hospitals of using a common process (initially PERS and now PIPER), there are serious deficiencies regularly reported to clinicians with no ready process for remediation of some blatant deficiencies. This is partly consequent on the shortage of maternal and neonatal beds in the tertiary hospitals (see previous recommendation).

b. The Victorian Regional Perinatal Morbidity and Mortality Project should be extended beyond the planned end date of 2018

Rationale:

The current project has engaged the rural centres and provided a vehicle for 2-way exchange with tertiary centres to which they refer. Following review at the conclusion of the project in 2017, a clearly defined and ongoing mechanism for similar exchange will need to be put in its place.

c. Complex Perinatal Services including Maternal Fetal Medicine and Genetics consultations are provided for rural centres using specific funding for face to face support as well as telemedicine

Rationale:

The interaction between specialists at tertiary centres and those delivering rural maternity services is critical to the provision of best practice care to rural women with often complex pregnancies and genetic or structural fetal abnormalities. It is impractical to expect these women to regularly travel to Melbourne for face to face consultations. Further expansion of telemedicine services can be supported with infrastructure development at both ends, service contract agreements between service providers, clear medico-legal agreements, communication guidelines (particularly addressing needs of women from non-English speaking background), addressing unique cultural requirements, facilitating reliable documentation at both sites and the capacity for prompt and accessible tertiary review if required.

7. Identification of best practice

Recommendation:

a. The relevant professional Colleges are engaged in any future attempt in the development of Guidelines

Rationale:

Previous Victorian attempts at maternity guideline development have often not directly involved the relevant Professional Colleges with consequent lack of clinician engagement. In future guideline development, RANZCOG welcomes the engagement of active clinicians in the relevant area of practice, rather than clinical administrators who may have strong guideline development skills but reduced capacity to interpret the available evidence in the relevant clinical context.


Summary of Recommendations

1. The availability, quality and safety of health services delivering services to women and their babies during the perinatal period

a. The principle of “Informed Choice for Women” should guide choices in maternity care.

b. A “Collaborative Model” of maternity care is prioritised.

c. The provision of Genetic Services should be reviewed, incorporating consultation with key stakeholders – particularly the Maternal Fetal Medicine Units.

d. All women are entitled to a comprehensive Family Planning Service as a component of their maternity care and therefore:

i. A hospital-based comprehensive Family Planning Service must be established at Werribee Hospital.

ii. The Austin Family Planning Service must be maintained within the Austin Hospital (including termination of pregnancy services) and clear lines of referral are required for women in need of second trimester termination of pregnancy (based on the geographical location of their place of residence).

2. The impact that the loss of Commonwealth funding (in particular, the National Perinatal Depression Initiative) will have on Victorian hospitals and medical facilities as well as on the health and wellbeing of Victorian families

a. Maternal Social and Psychological Health be given priority in the delivery of maternity care, both antenatally and postnatally.

3. The adequacy of the number, location, distribution, quality and safety of health services capable of dealing with high-risk and premature births in Victoria

a. Prioritising perinatal care in Victoria means ensuring that Neonatal Intensive Care and Special Care nursery capacity is urgently addressed.

b. Plans for the fifth NICU to be built at Western Hospital Sunshine should be progressed expeditiously.

c. Considerations regarding requirements of high risk patients in the North of Melbourne need to be considered with the expansion and development of services at the Northern Hospital.

4. The quality, safety and effectiveness of current methods to reduce the incidence of maternal and infant mortality and premature births

a. The current set of Victorian Maternity Performance Indicators should be maintained and strengthened with the correction of some obvious anomalies.

b. Reporting of Congenital Anomalies must be improved.


5. Access to and provision of an appropriately qualified workforce, including midwives, paediatricians, obstetricians, general practitioners, anaesthetists, maternal and child health nurses, mental health practitioners and lactation consultants across Victoria

a. Through the AHMAC, the Victorian and other Health Departments should put strategies in place to address the maldistribution of the health workforce including that AHMAC:

i. Mandate (as a condition of Commonwealth Funding) that medical schools have at least 35% of their medical school intake from a rural (secondary schooling) background.

ii. Mandate (via the addition of a new AMC Standard in the Australian Medical Council accreditation of the Medical College Specialist Training Programs) that the Medical Colleges have strategies in place in selection of trainees and their training that will enhance the specialist rural workforce.

6. Disparity in outcomes between rural and regional and metropolitan locations

a. The “PIPER” process for maternal and neonatal transfer should be urgently reviewed.

b. The Victorian Regional Perinatal Morbidity and Mortality Project should be extended beyond the planned end date of 2018.

c. Complex Perinatal Services including Maternal Fetal Medicine and Genetics consultations are provided for rural centres using specific funding for face to face support as well as telemedicine.

7. Identification of best practice.

a. The relevant professional Colleges are engaged in any future attempt in the development of Guidelines.

References

1. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. STANDARDS OF MATERNITY CARE IN AUSTRALIA AND NEW ZEALAND. March 2016.

2. Montgomery (Appellant) v Lanarkshire Health Board (Respondent) (Scotland), (March 2015).

3. Walker SP, McCarthy EA, Ugoni A, et al. Cesarean delivery or vaginal birth: a survey of patient and clinician thresholds. Obstet Gynecol. 2007;109(1):67-72.

4. Permezel M, Milne KJ. Pregnancy outcome at term in low-risk population: study at a tertiary obstetric hospital. J Obstet Gynaecol Res. 2015;41(8):1171-7.

5. Gardosi J, Clausson B, Francis A. The use of customised versus population-based birthweight standards in predicting perinatal mortality. BJOG. 2007;114(10):1301-2; author reply 3.

6. Gardosi J, Clausson B, Francis A. The value of customised centiles in assessing perinatal mortality risk associated with parity and maternal size. BJOG. 2009;116(10):1356-63.

7. Hogenbirk JC, McGrail MR, Strasser R, et al. Urban washout: how strong is the rural-background effect? Aust J Rural Health. 2015;23(3):161-8.

8. McGrail MR, Humphreys JS, Joyce CM. Nature of association between rural background and practice location: a comparison of general practitioners and specialists. BMC Health Serv Res. 2011;11:63.

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