Maternity care in Australia: a critical discourse analysis of key stakeholder influence in determining the primary maternity care reform agenda

A major program of reform has been announced by the Australian government that appears to be at odds with current general public perceptions regarding how safe quality maternity care is delivered. Australia is a society that has embraced the introduction of high technology across all aspects of life including childbirth in contrast to a primary maternity care model which reserves valuable obstetric services for only those women experiencing complications. The proposed reform does not come with consensus agreement and represents a change to traditional key stakeholder relationships with government. Maternity care provider groups involving obstetrics and midwifery have a long history of involvement in professional power struggles whilst consumer groups also contain polarised elements. Ongoing tensions exist as those who hold power to influence the direction of the reforms constantly assert their authority while those who do not hold the power make bids to seize power and redirect the reforms to suit their agendas. Critical discourse analysis was employed as the methodological framework in the context of Australian maternity services policy to better understand how knowledge and power have been used by key stakeholders for the purpose of influencing change. Interpretive analysis in this research was guided by the use of a neoliberal lens for the purpose of exposing the intrinsic drivers for change that are unrelated to key stakeholder influence. This approach has allowed power relationships to be examined and the forces driving change to be exposed. The analysis of relationships of power in maternity care has highlighted changes to historical positions including: Government and medicine; medicine and midwifery; medicine and consumers; and government and consumers. It is argued that these changes have been stimulated through the introduction of neoliberal values in publicly funded maternity services management. The rise in consumer influence has impacted strongly on the direction of change culminating in the proposed primary maternity reform agenda. The Australian government seeking to secure affordable maternity services has allianced to the reforms advocated by the key stakeholder collaboration incorporating consumer groups, midwifery, sympathetic health service managers and rural doctors. In contrast to the position of the collaborative alliance the obstetric discourse has been unable to provide government with solutions to escalating costs and workforce deficits associated with providing Australian women with safe maternity care. These findings have implications for the implementation process which is further challenged as general public confidence in the proposed reforms is being undermined in the newspaper media by a steady stream of fear inducing cautionary warnings emanating from the authoritative medical and obstetric expert claiming that lives of mothers and babies will be threatened by the proposed change. The general public are presented with a conflict, caught between the need for change and fear that change will undermine safe standards.