The Royal Women’s Hospital has released its new Strategic Plan for 2026–2030, setting out an ambitious vision to create “healthier futures for women and babies”. As Victoria’s leading specialist women’s hospital, what the Women’s chooses to prioritise matters. It matters for the thousands of women who give birth there each year, but it also matters because the hospital has considerable influence over maternity care, clinical practice and research across the state.

There is much in the new strategy to welcome. Women’s voices are prominent. Equity, inclusion and consumer partnership feature throughout. And, importantly, maternity care has been identified as one of six areas requiring “immediate, concerted and coordinated action”.

But read the maternity section closely and a more difficult question emerges.

Does this strategy actually confront the systemic problems in Australian maternity care, or does it mostly promise to make women’s experience of the existing system better?

That distinction has never been more important.

The release of the strategy comes at a particularly significant moment for women’s health in Australia. The newly established Senate inquiry into women’s health has put pregnancy, birth and postpartum care squarely on the national agenda, including women’s physical and psychological experiences of birth and the models of care that best support women’s long-term health.

We are also no longer talking about birth trauma as a marginal issue. Women have been telling us, loudly and repeatedly, that something is wrong. The NSW Birth Trauma Inquiry brought unprecedented attention to experiences of coercion, inadequate consent, loss of autonomy, disrespect and trauma within maternity services. Research has similarly challenged us to look beyond traditional measures of a healthy baby and a physically safe mother when deciding whether maternity care has been successful.

Against that backdrop, the Royal Women’s strategy makes some important acknowledgements. On page 17, it states that improving “experience and choice” from conception through to the fourth trimester is essential to improving clinical outcomes and reducing birth trauma. It promises to develop and scale models that improve “access, care continuity and choice”, and to embed a “trauma-informed, respectful and holistic framework for perinatal trauma”. It also commits to strengthening the evidence base around continuity of care models and birth trauma.

These are welcome words. But they are also remarkably non-specific.

Where is continuity of midwifery care?

Perhaps the most obvious example is continuity of care.

The evidence supporting midwifery continuity models is hardly new. Women who receive continuity from a known midwife or small group of midwives are more likely to experience spontaneous vaginal birth and less likely to experience unnecessary interventions, while also reporting greater satisfaction with their care.

The Royal Women’s itself acknowledges the importance of continuity. Earlier in the strategy, it specifically notes that First Nations families supported through culturally safe continuity models experience better health outcomes, stronger engagement and more empowered care.

Yet when we reach the maternity strategy, there is no specific commitment to significantly expand Midwifery Group Practice or other midwifery continuity models. There is no target for the proportion of women who should have access to continuity by 2030. There is no commitment to measure how many women want MGP but cannot access it. There is no discussion of removing eligibility barriers or redesigning workforce models so that continuity becomes the norm rather than an option available to a fortunate minority. Instead, the hospital will “strengthen the evidence base” around continuity of care.

At some point, however, we have to ask whether we have an evidence problem or an implementation problem.

And what about intervention?

Even more striking is what the maternity strategy does not discuss.

There is no explicit acknowledgement of Australia’s high and rising rates of maternity intervention. In 2023, 41 per cent of Australian women gave birth by caesarean section, 33 per cent had their labour induced and around 12 per cent had an instrumental vaginal birth. Labour was augmented for 15 per cent of all mothers — and for 27 per cent of women whose labour began spontaneously. Among first-time mothers having a non-instrumental vaginal birth, 22 per cent had an episiotomy; among those having an instrumental birth, the rate was 81 per cent.

These are not static figures. Among relatively low-risk first-time mothers, induction of labour increased from around 26 per cent in 2004 to 43 per cent in 2023, while caesarean section increased from around 25 per cent to 36 per cent over the same period. In Victoria, the overall caesarean section rate reached 42.6 per cent in 2023.

Australia’s caesarean rate also sits well above that of many comparable OECD countries. Recent OECD data put Australia’s rate at approximately 38 per cent, compared with around 21 per cent in France, 20 per cent in Denmark, 19 per cent in Sweden and 16 per cent in Norway.

Yet caesarean section, induction of labour, augmentation, instrumental birth and episiotomy are not part of the Royal Women’s maternity strategy discussion. Neither is supporting physiological labour and birth. This does not mean intervention is inherently bad. Modern obstetric care saves the lives of women and babies every day, and timely intervention is an essential component of safe maternity care. But that is not the same as saying every intervention currently occurring is necessary.

If a major maternity hospital is serious about transforming care, surely one of the questions it should be willing to ask is whether all women are receiving the right intervention, at the right time, for the right reason – and whether variations in clinical practice, institutional culture or models of care are contributing to intervention that might otherwise be avoided. A strategy genuinely committed to maternity reform could establish measurable goals around evidence-based intervention, physiological birth and unwarranted variation in clinical practice.

This one does not.

Treating birth trauma is not the same as preventing it

The strategy’s commitment to a trauma-informed and respectful framework for perinatal trauma is important. Women who experience traumatic births deserve knowledgeable, compassionate and timely support. But there is a fundamental difference between becoming better at caring for women after they have been traumatised and asking what maternity services can do to prevent avoidable trauma in the first place.

Some birth trauma arises despite exemplary care. Birth can involve unexpected emergencies, devastating complications and outcomes nobody could have prevented. But we also know that trauma is not always about what happened clinically. It can be about how a woman was treated while it happened.

Whether she was listened to. Whether somebody explained what was happening. Whether her consent was sought rather than assumed. Whether she felt able to say no. Whether her concerns were dismissed. Whether decisions were made with her or around her. Whether she emerged from birth feeling that she had been an active participant in her own care or merely the object of it.

Yet the maternity section does not explicitly address informed consent, coercion, refusal of recommended treatment or women’s autonomy in clinical decision-making. It promises “respectful” care without identifying disrespectful care as a problem.

That matters.

What exactly does “choice” mean?

The word choice appears repeatedly in the strategy, and it is an appealing one. The hospital promises to improve access, continuity and choice for women across Victoria. But choice only has meaning if women can actually access different options.

Does choice mean being able to choose Midwifery Group Practice? Does it mean choosing a known midwife? Choosing where to give birth? Being supported to labour physiologically? Having access to waterbirth? Choosing vaginal birth after caesarean where clinically appropriate? Declining an induction after receiving balanced information about benefits and risks?

Or does choice simply mean being offered several options within a model of care whose basic architecture remains unchanged?

Those are very different versions of woman-centred care.

Women need more than a seat at the table

To its credit, the Royal Women’s makes consumer involvement one of the strongest themes of its strategy. Consumers will be involved in governance, planning, design and evaluation and will help define measures of success based on what matters to women and families.

That is important.

But consumer engagement should not be confused with woman-centred maternity care.

A hospital can have consumer representatives on committees and still have individual women feel powerless in the birth suite. It can co-design services while women continue to struggle to access continuity of carer. It can collect patient feedback while maintaining policies and practices that make genuine shared decision-making difficult.

The real test of woman-centred care is not simply whether women have a voice in designing the system. It is whether an individual woman retains a meaningful voice when she is inside it.

Where are the measures that will tell us whether anything has changed?

Perhaps the biggest unanswered question in the strategy is how success will be measured. The hospital says a future strategic performance framework will establish implementation and outcome measures. Those measures will be critical.

By 2030, will more women have access to a known midwife throughout pregnancy, birth and postpartum? Will Midwifery Group Practice places have substantially increased? Will fewer women describe their births as traumatic? Will women report greater involvement in decision-making and greater respect for their autonomy? Will potentially avoidable interventions decrease? Will disparities in maternity experiences and outcomes narrow?

These are measurable things.

Without clear targets, however, it becomes difficult to know what “enhancing the experience of maternity care” actually means – and even harder to hold the hospital accountable for delivering it. If success is not defined, almost any improvement can be presented as progress.

Interestingly, other parts of the Royal Women’s strategy are prepared to be more explicit about structural problems. In discussing pelvic pain, the hospital identifies persistent barriers to care and commits to redesigning pathways, expanding workforce capacity and developing best-practice models. In abortion and contraception, it names stigma, cost, geography and workforce capability as barriers and proposes concrete system responses.

When it comes to maternity care, the language becomes noticeably more cautious.

The problem is framed primarily as one of experience, access and choice, rather than asking whether elements of the maternity system itself need fundamental reform. That is a missed opportunity.

The Senate inquiry gives us an opportunity to ask harder questions

The Royal Women’s should be commended for recognising birth trauma, continuity and choice as priorities. Their inclusion in the strategic plan is significant, and it provides an important platform from which meaningful reform could occur.

But Australia’s current conversation about maternity care requires us to go further. The Senate inquiry into women’s health provides an opportunity to ask questions that women, midwives, researchers, advocates and many clinicians have been asking for years.

Why do so many women who want continuity of midwifery care still struggle to access it? Why are intervention rates so high? What drives variation in maternity practice? How well are informed consent and refusal actually respected during pregnancy and birth? Why do women continue to describe experiences of coercion, disrespect and loss of autonomy? And why do models with a strong evidence base remain so difficult to scale?

Most importantly, we need to stop treating women’s experience of maternity care as something separate from the quality and safety of maternity care.

A healthy baby matters enormously. Clinical safety matters enormously.

But women matter too.

A woman should not have to emerge physically intact from birth while carrying psychological injuries caused by the way she was treated. Nor should respectful, relationship-based, woman-centred care be considered an optional extra once the clinical work has been done.

The Royal Women’s has described the maternity care it wants women to experience by 2030: respectful, trauma-informed, equitable, continuous and offering genuine choice.

The ambition is welcome.

Now we need to see the structural reform that will make those words true.

Sources

Australian Institute of Health and Welfare. (2025). National Core Maternity Indicators. Australian Government. National Core Maternity Indicators

Australian Institute of Health and Welfare. (2026). Australia’s mothers and babies. Australian Government. This is the source for the 2023 national figures, including the 41% caesarean rate, 33% induction rate, instrumental birth trends and augmentation data.  Australia’s mothers and babies

Consultative Council on Obstetric and Paediatric Mortality and Morbidity. (2025). CCOPMM 2024 annual report: For births and perinatal, maternal and child and adolescent deaths in Victoria in 2023. Safer Care Victoria.  CCOPMM 2024 annual report

Organisation for Economic Co-operation and Development. (2026). OECD Health Statistics: Surgical procedures — Caesarean section. OECD Data Explorer. OECD caesarean section data