It is time for people power to drive this change — to demand politicians and health services be accountable.
Maternity services in Australia are in bad shape. Nowhere is this more evident than in rural and remote communities, where services have been in steady decline for decades.
Rather than prioritising the needs of women and families, our system continues to hide behind bureaucratic and professional excuses that protect institutions, colleges, and governance frameworks.
The result is a slow but deliberate erosion of care — a case of the “ideological perfect” killing the “pragmatic good.”
Politicians, bureaucracies, and peak medical bodies have failed rural communities. Their loyalty has been to systems and institutions, not to people
A national decline
Maternity care is under strain nationwide. Private obstetric providers are closing — the Northern Territory now has no private obstetric services, Tasmania only a few, and many regional services in NSW and Victoria are under threat.
My colleagues report that obstetrics is no longer a favoured discipline among trainees; gynaecology subspecialties and IVF are far more attractive, fuelled by stronger private sector demand.
At the same time, the private hospital system is struggling to recruit and retain midwives, restricting services further.
Australia delivers around 290,000 (90,000 in NSW) babies each year, around 25% of them in the private sector. Yet fertility rates are falling, and the workforce is concentrating in urban centres.
Of the 2200 registered obstetricians and gynaecologists, over 82% are based in metropolitan areas (MMM1). Only around 8% are in larger regional centres, leaving women in MMM3+ regions — around 2.5 million females — with limited access to safe, timely care close to home.
Bureaucratic barriers and institutional safety
Arguments from bureaucratic institutions often focus on “safety”—but this is usually safety as defined for organisations, not for actual communities.
This rationale overlooks the very real risks faced by rural families: unplanned births at the roadside, deliveries in ambulances, labours along the bumpy country highways, and lengthy delays during emergencies.
These situations rarely make it into official statistics, allowing health authorities and professional colleges to sidestep responsibility.
This approach gives currency for the bureaucracy to hide behind legitimate questions raised by the politicians and public. Evidence indicates that rural maternity services are safe, with fewer interventions, caesarean sections, and complications.
The system, as it currently operates, is designed to serve professional bodies and health services, not people.
It has failed to integrate metro, regional, and rural services into a cohesive framework that delivers safe, high-quality care where women live. The result is a hollowing out of rural obstetrics, a hub and spoke model without the spokes.
Related
Critical role of rural generalist obstetricians and anaesthetists
Rural generalist obstetricians and RG anaesthetists are vital proceduralists in rural health. They are not only essential for local maternity services but also for emergency surgery, resuscitation, and broader procedural care.
When a rural town supports these experts, it supports an operating theatre, midwives, theatre nurses, and the visiting proceduralists who depend on them. Without GP proceduralists, there is no theatre, no deliveries, no long-acting contraception, no safe terminations, and no emergency response capacity.
Yet RG obstetrics is in decline.
In NSW, fewer than 40 practicing RG obstetricians remain — down from nearly 200 just decades ago. Across Australia, procedural sites have fallen from over 400 in the 1990s to fewer than 200 today.
Training pathways are narrowing, with only two GP obstetric trainees in NSW across 2023 – 24 (though a minor increase to four in 2025 offers hope). Worse still, RG obstetricians are treated as second-class practitioners in tertiary training settings, a professional hostility that further diminishes this vital workforce.
A failing system and the “let it die” approach
Health services and local health services (LHDs/LHNs) are not incentivised to sustain rural maternity units. Rural procedural hospitals that fail to perform procedures face no penalties.
In fact, “doing less” can be financially advantageous, freeing funds to cover locums and other costs. There are no accountability mechanisms, no KPIs, and no consequences when essential rural services quietly disappear.
This has fostered a culture of passive neglect — an unwritten rule: let it die, just don’t be seen killing it.
But letting a service die is the same as killing it. Many rural hospitals remain technically “open” but function only in name, providing a façade of access while delivering no real care.
Rural generalist opportunity — and the risk of collapse
There is, paradoxically, a growing interest among medical students in rural generalism. Around 13% of Australian medical students express interest in general practice, another 6% specifically in the rural generalist pathway.
This is a remarkable opportunity to rebuild a sustainable workforce.
Yet by the time these trainees graduate, many rural hospital procedural sites may no longer exist in any meaningful form. Examples abound: towns such as Cootamundra, Lithgow, Tumut, and Kempsey — once thriving procedural centres — are now shadows of their former selves, unable to support and train rural generalists in practice.
Conclusion: a call for community-driven change
We cannot continue doing the same things and expect different outcomes.
Rural maternity care in Australia is collapsing, not from sudden shocks but from deliberate neglect. Politicians, bureaucracies, and peak bodies have failed rural communities. Their loyalty has been to systems and institutions, not to people.
Safety must mean more than governance. It must mean a mother delivering safely close to home, an emergency managed without fatal delay, and a rural community knowing their health services will be there when it counts.
The future of rural maternity services will not be saved by health bureaucracies alone. It will require real investment, transparent accountability, and community-led advocacy.
People power must now drive this change — to demand that politicians and health services reorient their priorities towards the women, families, and communities they exist to serve.
Associate Professor Alam Yoosuff is a rural generalist GP, a board director for the Murrumbidgee LHD and Murrumbidgee PHN. He is a clinical academic at the University of Notre Dame.
This article was first published on Professor Yoosuff’s substack. Read the original here.