Jade van Krimpen is 34 weeks pregnant with her third child and at this point she has no idea where it will be born. She is in Gladstone, Queensland, where the hospital has been on a birthing bypass for months because of staff shortages.
Shortages of midwives and obstetricians in rural and regional Australia have forced maternity units to close or reduce services, leaving women facing the prospect of having to drive long distances, juggle hotels, and other children and partners just to find a safe place to give birth.
“My other two children were both born in Gladstone. I don’t really know where this one’s going to be born,” Van Krimpen says.
“Some people have been told if you’re past [a certain level] of dilation, they won’t send you to Rockhampton [100km away]. I’ve been told you could be here [in Gladstone], but there are no epidurals. We’ve come up with at least five different plans – one might work, none might work.
“It’s up in the air, what having this baby looks like.”
Does she drive? Leave the other children? How does she get back, with a newborn baby? Does she need a hotel?
“It’s going against everything we’ve been told we’re supposed to do in labour: being relaxed, in a comfortable environment. It’s not practical and it’s a massive financial burden as well,” Van Krimpen says.
The situation is particularly dire in regional areas – leading to births on the side of the road, “moral distress” for health workers, and women often isolated from partners and children while they give birth in distant towns.
Figures from the Australian Institute of Health and Welfare show that in 2020 the birthplace of more than 1,500 babies nationally was listed as “other”. That includes many who were “born before arrival”, meaning before the mother could get to hospital. That might be an unplanned home birth, or a birth in a car or on the side of the road.
Midwives and obstetricians say the situation in rural and regional Australia was deteriorating for years, then worsened when the pandemic hit, putting intense pressure on health workers and the system. And it has driven the gap between city and country services wider still.
‘There’s anxiety, there’s despair’
In Geelong, “workforce shortages” will close the Epworth hospital’s maternity ward by the end of March, leaving about 100 patients looking for help elsewhere.
Elise Davey, the practice principal at a Geelong medical centre and a women’s health advocate, says women are in “limbo land”, with only a handful of public birthing suites left in town and another handful in a Catholic hospital, which limits reproductive choices.
“We’ve lost that now and we will not get it back. There will be decades of women complaining that we’re underserviced,” she says.
Midwives have warned of staff shortages in New South Wales, with Auburn, Wollongong and Coffs Harbour hospitals struggling to fill vacancies. They say there is a “significant” shortage in Western Australia, leading to potentially unsafe environments. In South Australia, the town of Gawler had “no room at the inn” at Christmas, with the birthing unit shut due to staff shortages. There are similar stories in Tasmania.
The shortages are patchy across the nation and hard to quantify because of the mix of private and public services run by the different states and territories, but experts overwhelmingly agree the crisis is disproportionately affecting rural and regional Australia.
Christine Catling is an associate professor in midwifery at the University of Technology Sydney and a research fellow of the National Health and Medical Research Council.
She says maternity services are “in the middle of a massive crisis” after years of experiencing an ageing workforce, where early-degree midwives are “ground down” by a system that doesn’t allow them to deliver continuity of care.
Not being able to form a relationship with the mother and feeling that there is too much pressure to intervene instead of delivering “gold standard care” is leaving them disillusioned, she says, so they leave.
“They have a moral injury, a moral distress, this human factor of knowing you need to do the right thing and knowing how to do the right thing but having structural issues around you, [most] of all the staffing issue, and you cannot follow up that woman because you’re working on the floor and you know that woman would benefit from seeing you,” Catling says.
She says there was talk of the “looming workforce crisis long before the pandemic but the pandemic has exacerbated it”. “We need to blow up the maternity service and start again.”
Jemma Manwaring is a local advocate who runs the Save Gladstone Maternity Ward Facebook page and has collected horrifying stories.
One woman in the middle of miscarrying went to Gladstone hospital, but with no obstetricians available was transferred at 3am to Rockhampton. She was away for three days, leaving her two-year-old daughter and fiance in Gladstone. By the time she got back, she struggled to breastfeed.
Another woman, pregnant with her sixth baby, said three of the first five came without warning. “I will definitely have my baby on the way to Rockhampton,” she said.
Others describe traumatic rides in ambulances while in labour.
“Both my husband and I suffered flashbacks, anxiety and have gone from planning another baby to operations to ensure we don’t fall pregnant again. It’s traumatised us beyond belief,” one woman said.
Another woman, too terrified get stuck far from a hospital, will go to Brisbane a month before she is due and says she is lucky she can afford it.
One woman had an emergency birth in Gladstone, the baby born within an hour of arriving at the hospital. “If I had ignored my intuition and attempted to go to Rockhampton, she would have been born on the highway,” she said.
“There’s anxiety, there’s despair, there’s disbelief that this can happen to us,” Manwaring says.
‘Absolutely smashed with Covid’
The president of the Australian College of Midwives, Joanne Gray, agrees with Catling that many students entering the system become frustrated and leave. The ideal model, she says, is where a midwife can see the mother through postnatal care and talk to her about how she mothers, breastfeeding, pelvic floor health and birth trauma.
“The biggest worry, when I think of the overall picture, is that women aren’t getting access to the best model of care,” she says.
Health department modelling from 2019 – before the pandemic – showed Australia would have enough midwives through to 2030 but that there would be a “maldistribution”, leaving vacancies in rural and regional areas.
The pandemic also caused a population shift, with people flooding into towns that were not prepared. And births are getting more complicated with the age of mothers rising and chronic diseases more common.
It is not just midwives. Obstetricians are also in short supply in many places. Dr Benjamin Bopp, the president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, says GP obstetricians (who are not specialists but can perform emergency caesareans and deal with other emergencies) form the “backbone” of many rural, regional and remote maternity services.
Those services were also the hardest hit by nationwide GP shortages. “General practice just got absolutely smashed with Covid,” Bopp says.
“Hospitals stopped doing things, sent people to GPs and then they said, ‘Can you vaccinate the whole population’.”
Fewer GPs are willing to take on obstetrics or to move outside the big centres, Bopp says.
There are “unprecedented workforce vacancies” for obstetric doctors in Queensland, according to a leaked letter reported by the ABC, which are threatening rural maternity services (a forum to discuss potential solutions will be held on 2 March).
In Gladstone, Van Krimpen says she is feeling “really anxious” about the possibility of driving to Rockhampton heavily pregnant, then back with a newborn.
“It makes me really sad that not only myself but other women have to go through this in 2023,” she says.
“This will be my last child and I didn’t think this was the way it was going to go.”
