Inquiry into the Thriving Kids initiative

ACM Submission

Issued October 2025

Inquiry into the Thriving Kids initiative

The Australian College of Midwives

The Australian College of Midwives (ACM) is the peak professional body for midwives in Australia. ACM represents the professional interests of midwives, supports the midwifery profession to enable midwives to work to full scope of practice (SoP), and is focused on ensuring better health outcomes for women, babies, and their families.

Midwives are primary maternity care providers working directly with women and families, in public and private health care settings across all geographical regions. There are 34,347 midwives in Australia and 1,506 endorsed midwives1. ACM is committed to leadership and growth of the midwifery profession, through strengthening midwifery leadership and enhancing professional opportunities for midwives.

Terms of Reference

This submission does not directly address the Terms of Reference. ACM is providing relevant additional input to the inquiry which supports the Terms of Reference.

Background

The current inquiry focuses on supporting parents to identify children with developmental delay or autism early, and systemic support for these children and their families. We note that certain trends in maternity care in Australia have the potential to increase the incidence of children with autism and developmental delay and focus on these areas in addition to support for early intervention should be prioritised. Risk factors for development of autism and developmental delay include preterm birth2, small for gestational age3, caesarean section4, preeclampsia5, maternal anxiety and depression6, 7, and exposure to medications such as syntocinon (used to induce and augment labour) and medical pain management such as epidural8.

Midwifery Continuity of Care (MCoC)

MCoC is a maternity care model where women see the same midwife or small group of midwives throughout their perinatal experience. MCoC provides evidence-based, high quality, high value maternity care. Women and babies experience reduced interventions and better outcomes, both physically and psychosocially9-11 with benefits demonstrated for women experiencing both low-risk and complex pregnancies. MCoC improves satisfaction with the birthing experience and can reduce birth trauma12. MCoC provides preventive healthcare as women and babies cared for in this model experience improved physical and psychological outcomes, leading to reduced long-term morbidity.

Midwives provide MCoC in publicly funded models and in private practice. The Midwifery Futures Report recommendation 8 advocates for MCoC models being available to all women regardless of risk status. Continuity of care models such as Midwifery Group Practice (MGP), where women receive care from a known midwife across the pregnancy continuum, are highly sought after, and women continue to express demand for these publicly funded models of care. However, women in Australia have limited access to MGP programs due to geography, waitlists, staff retention and certain exclusion criteria impeding women accessing the program13. The ACM calls for increased access to midwifery-led continuity of care models for all women.

An adapted MCoC model which provides primary maternity care during the antenatal and postnatal period. This model of care, known as Maternity Antenatal Postnatal Service (MAPS), has demonstrated

positive outcomes, and is well received by women14. It is the ACMs position that all women in Australia should have access to a full MCoC model, and we recommend all women for whom this service is not currently available should be offered care in a MAPS model, followed by standard care. The ACM cautions against health services assuming or implementing MAPS as an acceptable replacement for full MCoC and defaulting to MAPS models of care due to assumptions about midwives’ preferences or challenges setting up MCoC models.

MCoC is protective against the development of developmental delay and autism in a range of ways. Women receiving care in an MCoC model are less likely to give birth preterm15, which is associated with the development of autism2. Lower cognitive scores and behavioural challenges are observed in children born preterm, and these persist into adulthood16. MCoC improves breastfeeding rates17, which reduces the incidence of autism and developmental delay18, 19. MCoC also decreases rates of intervention such as caesarean birth and induction of labour20, and appears to be protective against perinatal mental health conditions21, 22, all of which reduce the likelihood of autism and developmental delay4, 6-8. Despite efforts to increase continuity of care in all jurisdictions, currently only 35.6% of women are receiving full continuity of care, with 11.3% receiving care in a Midwifery Group Practice (average of the three states reporting on proportion of women receiving continuity of care)20. Given the significant impact MCoC has on all these outcomes, and their impact on incidence of autism and developmental delay, increasing MCoC would translate to reduced rates of autism and developmental delay. While this is not the focus of the current inquiry, consideration of prevention is essential alongside diagnosis, early intervention and support.

Intervention in maternity care

The intervention rate in Australia is comparatively high, and is steadily rising23. While sometimes these are necessary and lifesaving procedures, these interventions can result from what is referred to as ‘the cascade of intervention’24, which often commences following the use of exogenous oxytocics to induce (initiate) or augment (speed up) labour. In 2023, 32.7% of women giving birth in Australia had an induced labour25. The rate of caesarean sections in Australia is 40.6%, and the rate of instrumental birth is 10.9%23. This is in contrast to the World Health Organization recommendation that when caesarean section rates rise above 10% there is no evidence of decreased maternal or neonatal mortality26. In effect, this means that 30% of mothers may be undergoing unnecessary caesarean sections in Australia. Caesarean section and induction of labour are both associated with increased rates of autism4, 8. Models of care that reduce the rate of unnecessary intervention should be prioritised. As noted above, MCoC offers an evidenced protective factor of reducing rates of induction of labour and operative birth whilst optimising safe outcomes9, 27. Policies that promote unnecessary interventions should be revised. Other strategies to reduce intervention rates are to implement and upscale publicly-funded homebirth, and to enable admitting rights for Privately Practicing Midwives (PPMs) nationally, as PPMs have among the lowest intervention rates of any care model20.

Breastfeeding and the Baby Friendly Health Initiative

Improving breastfeeding is a critical population health initiative, reducing incidence of long-term chronic health conditions for the infant and ovarian and breast cancer rates for women who breastfeed16. A cohort study of over 570,000 children in Israel found that longer and exclusive breastfeeding reduced the likelihood of developmental delay18. A meta-analysis found that breastfeeding significantly decreased the incidence of autism spectrum disorder, with breastfeeding for six months associated with a 54% reduction in the risk, and breastfeeding for 12-24 months associated with the greatest impact on incidence of autism19.

Baby Friendly Health Initiative (BFHI) is an internationally recognised accreditation framework to protect, promote and support breastfeeding in hospitals and community health facilities. BFHI is utilised world-wide and was originally developed by the World Health Organization (WHO) and UNICEF. BFHI is led by the ACM in Australia.

BFHI provides a low-cost, high-yield intervention to considerably improve breastfeeding rates and improve a range of perinatal outcomes, impacting maternity care, preventative health, primary health care and closing the gap targets in Australia. Despite system-wide BFHI implementation being identified as a priority in the National Breastfeeding Strategy, and linked to key national and jurisdictional health strategies, it is not mandated or prioritised in Australia (with the exception of Tasmania). The National Breastfeeding Strategy implementation plan identified activities under 10 action areas. Priority 2 / Action 5 – support for breastfeeding in health care settings / the Baby Friendly Health Initiative (BFHI) has not been funded or actualised.

PRIORITY 2—SETTINGS THAT ENABLE BREASTFEEDING

2.1 Action area—Baby Friendly Health Initiative

Only 23% of Australian hospitals are currently accredited nationally. The 2023 World Breastfeeding trends initiative Australian report card scored an alarming 33/100. Rankings for national policy, governance and funding scored only 1.5/10. Further, AIHW breastfeeding data indicates large discrepancies in exclusive breastfeeding rates and challenges with breastfeeding data indicators with respect to collection, validity and digital health approach.

ACM advocates for jurisdictional mandating of BFHI accreditation in hospital and community settings, as it is in Tasmania. ACM recommends the implementation of BFHI in all birthing and community health services as a solution to improving breastfeeding rates. It is important that Maternal, Child and Family Health services are accredited, not just birthing services.

Care for First Nations families - Birthing on Country / Birthing in our Community

For First Nations women and babies, intrapartum care in their community is culturally important. Deep spiritual connection to their homeland is a part of their heritage, and ensuring their babies spiritual connection to the land by Birthing on Country is deeply significant28. In addition, First Nations women

often experience racism from health professionals, and travel to distant urban hospitals does not allow for inclusion of family support²⁸.

First Nations babies are twice as likely to be born preterm as non-Indigenous babies, which leads to increased morbidity and mortality rates¹⁵, including increased rates of autism², and First Nations mothers are 2-3 times more likely to die in childbirth²⁹. In the Birthing in Our Community model, designed by the Mater Mothers’ Hospital in Brisbane, women are cared for by a midwife in a continuity of care relationship alongside a First Nations Family Support Worker. Care in this model has shown a 5.34% to 14.3% reduction in preterm births, along with a saving to the health care system of $4810 per mother-baby pair (in a 2023 study)¹⁵.

Birthing on Country / Birthing in our Community models are being implemented around Australia, but face barriers. These include legislative²⁹ and other challenges, including requirements for medical practitioner presence to license a Level 2 private maternity facility, inflexible and expensive unsubsidised insurance policies for hospital birth, and funding³⁰. The RISE framework has been proposed and tested as a model to support widespread implementation of Birthing on Country models³¹. Some examples of Birthing on Country models include Waminda, Baggarrook midwifery care | The Royal Women’s Hospital and Westmead Dragonfly Midwifery - WSLHD.

Perinatal mental health challenges

Depression and anxiety are common both during pregnancy and postnatally, with 15-20% of mothers experiencing mental health challenges³². Fathers also experience perinatal mental health challenges, although this is not well understood in the Australian population³³. Maternal antenatal depression is associated with preterm birth and low birth weight³⁴, and also impacts negatively on child development throughout infancy, childhood and adolescence³². Maternal anxiety and depression are associated with both autism and developmental delay⁶, ⁷, so early intervention and support for women experiencing mental health challenges during the perinatal period would be protective against the development of autism and developmental delay. MCoC builds relational trust between clients and midwives, facilitating communication and rapport that positively impacts women’s mental health. In a continuity relationship, mental health challenges are more likely to be disclosed and also midwives are more likely to identify changes in mood and behaviour. Furthermore, the trusting nature of this relationship can increase effectiveness of midwifery counselling and debriefing.

All current MBS items for endorsed midwives are deemed to be within the antenatal, intrapartum or postnatal period (to eight weeks postpartum). Midwifery scope of practice extends to sexual and reproductive health care and child and family healthcare³⁵. However, there is no General Consult item for which an endorsed midwife has requesting rights, and which is not timebound to the pregnancy continuum to eight weeks postnatal. MBS item 44 (which is a preventative care 40-minute Level D GP item) must be amended to include requesting rights for endorsed midwives, or a new item approved to enable women to access their care from an endorsed midwife and not be required to go to a second health professional for their referral or prescription.

Autistic parents

Autism spectrum disorder is influenced by both genetic and environmental factors³⁶. Several environmental factors associated with the perinatal period have been discussed above, however it is important to also consider the genetic link. Increasing early diagnosis of autism could be achieved by greater support for new parents where one or both parent is Autistic. It is also important to bear in mind

that many Autistic women are undiagnosed, and it is not uncommon for a diagnosis to occur following the birth of a first child.

The perinatal period and transition to parenthood are challenging for any woman and family, but for an Autistic woman these challenges can be significantly exacerbated². Autistic people are more likely to be dissatisfied with their birth and postnatal care, and to develop postnatal mental health challenges³. Autistic mothers face challenges including difficulty relating to healthcare professionals, feeling isolated as a mother, and difficulty knowing where to turn for parenting support³⁷. In this context, additional targeted parenting support is needed for Autistic mothers, and this support would likely increase rates of early diagnosis of autism in children of Autistic mothers.

MCoC has extensive benefits for all parents, as outlined above. For families with one or both Autistic parents, the relational nature of MCoC allows for the development of trust, an understanding of specific needs and preferences by the midwife, and coordination of care and referral needs through one healthcare professional. The additional psychosocial support and education provided, along with more flexible appointment lengths, have a significant potential to mediate overwhelm and reduce the potential for women to disengage from services.

Pre-registration training about autism for midwives is extremely limited or non-existent. Likewise, continuing professional development opportunities in this area are rare. In order to appropriately care for Autistic mothers and fathers, midwives need relevant training co-designed by Autistic people. If midwives and other maternity care providers were more equipped to recognise autism in the parents they care for, care would be more tailored, and more parents would be supported to identify neurodiversity in themselves, which would increase early diagnosis in their children.

While there is a significant body of research related to Autistic children and the impact of perinatal experiences on the development of autism in the baby, there is limited research about the healthcare experiences of Autistic women during pregnancy, birth and in the postnatal period². Further research in this area would improve understanding of the existing health inequalities for Autistic women during the childbearing year, the experience of Autistic mothers and fathers, and effective adjustments to improve the outcomes and experience of Autistic parents.

The first 2,000 days and Midwives in Maternal, Child and Family Healthcare

The International Confederation of Midwives (ICM) and World Health Organization (WHO) recognise Child and Family Healthcare as among the essential competencies of a midwife³⁸, ³⁹. ICM’s definition of the scope of practice of a midwife states: ‘The midwife has an important task in health counselling and education, not only for the women and gender diverse people they serve, but also within families and communities. This work should involve antenatal education and preparation for parenthood and may extend to sexual and reproductive health care, and care for infants and young children.’ A midwife’s individual scope of practice adapts and grows as they develop new skills and expand their knowledge³⁵. Currently in Australia, midwives can work in MCFH roles in every state and territory, however some jurisdictions or health services require or prefer midwives applying for these positions to hold a dual nursing qualification.

Endorsed Midwives are midwives who have met the requirements of the Nursing and Midwifery Board of Australia to qualify to prescribe scheduled medicines. This means that they can provide primary maternity care services which meet all the perinatal needs of a well woman and baby. They can also provide care outside of the perinatal period, for example Sexual and Reproductive Health Care (SRHC) and Maternal,

Child and Family Health (MCFH). Endorsed Midwives practice in public and private health services, in group practices, in General Practice clinics, and in private practice.

Midwives have a key role across the first 2,000 days in engaging families, providing care across the continuum including birth, and intense postnatal support during the early post birth period. Care provided by a midwife during pregnancy, labour and birth and through the first eight weeks after birth is pivotal in improving outcomes in a range of national core maternity indicators such as antenatal visits, low birth weight, preterm birth, stillbirth and neonatal death, for birth outcomes, perinatal mental health and in the initiation and continuation of breastfeeding. Just as the first 2,000 days provides a rare opportunity to impact the health of the family at a time of peak motivation and impact the start to life in an ‘once in a lifetime’ period, the role of the midwife in the first 2,000 days affords a unique opportunity. The level of engagement and continuum of care (particularly across the intrapartum period) provided by the midwife are unlikely to be able to be facilitated by other clinicians.

If midwives are supported to provide ongoing care for families post eight weeks (with appropriate education and referral pathways), this would establish increased continuity of care and contribute to early diagnosis of autism and developmental delay. Some barriers to midwives working in MCFH include jurisdictional requirements for dual qualification and a lack of Medicare and PBS items claimable by endorsed midwives outside of the perinatal period.

For further information about midwives and the first 2,000 days, please see ACM’s submission: The Role of Midwifery in the First 2000 days.

Recommendations:

• Midwifery Continuity of Care should be accessible for all women in Australia, regardless of risk status.
• Birthing on Country / Birthing in our Community programs should be accessible for all First Nations women.
• Baby Friendly Health Initiative should be mandated and funded nationally, both for birthing facilities and Maternal, Child and Family Health services.
• Midwives should be enabled to provide Maternal, Child and Family Healthcare, with appropriate training and referral pathways.
• Publicly funded homebirth should be implemented / upscaled nationwide.
• Admitting rights for Privately Practicing Midwives should be enabled nationwide, with incentives for health services to comply.
• Rates of unnecessary intervention such as caesarean section and induction of labour should be reduced.
• Pre-registration and continuing professional development about autism should be provided for maternity care providers.
• Support for women experiencing mental health challenges during the perinatal period should be increased.

Conclusion

Alongside focus on early diagnosis and intervention and support for families with a child with autism or developmental delay, consideration must be given to reducing rates of autism and developmental delay. Perinatal events contribute to environmental causes of autism and developmental delay, and we have provided recommendations to reduce these environmental factors, including increased access to

Midwifery Continuity of Care models. A strategy for increasing early diagnosis of autism is to increase continuity of care and support for Autistic parents, alongside education for maternity care providers. Midwives working in Maternal, Child and Family Healthcare would increase continuity and contribute to early diagnosis of autism and developmental delay. Changes to enable this are proposed.

Helen White
Chief Executive Officer

E: redacted

W: https://www.midwives.org.au

Alison Weatherstone
Chief Midwife

E: redacted

Attribution: Aya Emery, ACM Midwifery Advisor.

Consent to publish

ACM consents to this submission being published in its entirety, including names.

Consent to provide further information

ACM is available to provide further expert opinion and advice if required.

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