During pregnancy, expectant women are presented with an array of choices, and perhaps the most important of these is where to give birth.
For the vast majority of Australian mothers, birth is an event that takes place in a labour ward. According to the most recent figures from the National Perinatal Statistics Unit (NPSU), in 2004 about 97.3% of women had a hospital birth. Factors that influenced this decision included a fear of complications, which can translate into a desire to be as close as possible to a range of modern medical technology.
However, despite the near-monopoly of hospitals on the Australian way of birth, other alternatives do exist. While maternity wards are the province of (predominantly male) obstetricians, both birth centres and homebirths are usually overseen by female midwives. Childbirth remains a zone of ideological difference between the high-intervention technological approach often favoured by obstetricians and the more natural, low-intervention path followed by midwives.
In Western countries, a shift away from the traditional practice of giving birth at home began during the 1950’s, at a time when women were being informed, probably incorrectly, that birth in a hospital was safer.
Hospital births with no interventions are very rare in Australia. Nearly all birthing women in hospital experience one or more of the following: induction or speeding up of labour, an epidural (spinal injection) or other pain-killing drugs; episiotomy (cutting of the perineum to widen the opening); caesarean section; and forceps or vacuum delivery. The incidence of all types of intervention is higher in private hospitals than public facilities. According to natural birth advocate and author Dr. Sarah Buckley, “We don’t know what the long-term risks of medical drugs and procedures around the time of birth may be for the offspring”.E
In the case of some interventions such as caesarean sections, the figures are showing a steady increase, despite an elevated risk of death for the mother. Elective caesareans are becoming more common among affluent prospective mothers, and obstetricians may encourage women to agree to a caesarean in order to avoid the disruption to their schedule created by attending births at unsocial hours. In 1991, when the NPSU started compiling annual data, Australia’s caesarean rate was 18%. By 2004, it had climbed to 29%, despite a World Health Organisation recommended upper benchmark of 15%.
Unfortunately, financial considerations also play a role. In our litigious society, doctors are nearly always sued for using too little technology rather than too much, and women may sue if they believe that vaginal birth difficulties could have been avoided by a caesarean.
At a birth centre
Birth centres are facilities that are often located inside hospitals, but are staffed and usually run by midwives. This birth option is suitable for women with low-risk pregnancies and no major medical risk factors. It accounts for about 2% of Australian births.
In several important respects, a birth centre differs from the more regimented hospital environment. There tends to be a more easy-going atmosphere, and the advantages of giving birth at home are coupled with fast access to hospital facilities if they are needed. Birth usually takes place in a private room, and the woman and her partner have a greater role in making decisions, for example by deciding who attends the birth. Usually the same midwife is present throughout the labour.
Here, birth is far more likely to be regarded as a natural act rather than a medical procedure. Midwives generally follow a philosophy of non-interference except where necessary, and only essential caesareans are carried out, following transfer to a maternity ward. Although epidurals are generally not provided, other types of pain relief may be available. As the use of pain-killing drugs is low, babies are born in a fairly alert state, and can start breast-feeding quickly. Surveys have found that mothers giving birth naturally report a greater satisfaction with their experience.
Some doctors’ groups have criticised birth centres, claiming an increased risk of infant mortality. However, a study released this year found that among low-risk women the chances of this occurring were significantly lower than in conventional hospital settings, particularly for second and subsequent babies.
Although access to a birth centre is available free of charge, birth centres are only capable of servicing a small minority of Australian births, and availability of places is a major issue. Furthermore, small birth centres, located generally in regional centres and staffed by local doctors and midwives, are being closed down across the country, reflecting an increasing under-provision of health facilities in rural areas. A predictable consequence of this policy is an increasing incidence of roadside births, as women drive for hours in labour to reach the nearest maternity hospital.
The option of homebirth
For healthy, low-risk pregnancy involving women who trust their bodies, homebirth is an option worth considering. This involves continuity of care with the same midwife throughout pregnancy, birth and the early postnatal period. A homebirthing woman is encouraged to check out a prospective midwife carefully, to find the carer with whom she is most comfortable.
The advantages of homebirth are broadly similar to those of birth centres. In Australia, an estimated 70-80% of homebirthing women give birth without any interventions, and the caesarean rate remains between 5-10%. Surroundings are familiar, and can be made as relaxing as possible. There is a maximum of privacy, with no unexpected intrusions. The woman can make as much noise as she wants, and may be accompanied by her partner, close friends and family, and sometimes children. After the birth, the mother and baby are not separated, and can bond immediately.
Nevertheless, most Australian obstetricians are unsupportive of homebirth. Some have claimed in public that homebirth carries a higher risk, although this is contradicted by the best medical evidence. Figures from overseas indicate that homebirth is as safe as, or safer than, hospital birth. Moreover, the risk of infection for both mothers and babies is reduced.
While homebirth is legal in all Australian states, to a greater degree than in most other Western countries it is still regarded as being on the fringes, and unjustifiably tends to be seen as irresponsible on the basis of its rarity. Women who decide on a homebirth may have to contend with the views of anxious friends and family members, and biased advice from doctors. In this regard, the homebirth support groups found in many larger population centres may be helpful.
NPSU figures for 2004 show that 589 Australian births (0.2% of the total) took place at home, although this figure is likely to be higher than reported. Women who opt for a homebirth tend to be older and better educated, and are more often health professionals themselves.
Factors working against homebirth in Australia include the significant cost, usually between $2,000 and $3,500, of employing a midwife. Normally this must be paid by the family, although a few health insurance companies do cover midwifery fees. Sometimes it is possible to find a place in one of the small-scale state government-funded homebirth programs that are running in New South Wales, Western Australia, South Australia and the Northern Territory.
However, a different picture exists in some other countries. In the Netherlands, which has the highest homebirth rate in the Western world, an estimated 36% of women plan to give birth at home. In this midwife-centred system, the state does not provide funding for an obstetrician unless one is needed. The UK Government is also actively encouraging homebirth, partly as a means of reducing the incidence of unnecessary caesareans, and it plans to fund a homebirth option for all pregnant women by 2010.
One popular option for homebirths and in birth units is a specially designed birthing pool. Originally designed to relieve pain during labour, water birth now frequently involves giving birth underwater. Large studies and experience indicate that it is a safe option for the mother and baby.
Advantages include the pain-dulling effects of relaxation, which in turn helps the uterus to contract, facilitating labour. Water also offers a greater feeling of privacy, facilitates changing positions during labour, and decreases the stress hormone adrenaline while encouraging helpful endorphins (for pain relief) and oxytocin (to help with contractions.)
Midwifery under threat
Overseas, one-on-one midwifery care is provided by the state in New Zealand, the Netherlands and parts of Scandinavia. About 78% of New Zealand women have a midwife as their primary carer, and an estimated 7% plan to give birth at home. In the UK, midwife support is free, but the woman cannot choose her midwife, and may have two different midwives caring for her during pregnancy and birth.
At present in Australia, there are an estimated 50 independent midwives located across the country, although in Western Australia and the Northern Territory other midwives are employed directly by the state or territory authorities. ‘Lay midwives’, those who have not been initially trained as nurses, have achieved excellent outcomes, but cannot practise legally in most states.
In Australia, the midwifery profession has been steadily marginalised over time in favour of obstetricians, and Australian consumer organisation Maternity Coalition warns that midwives are now leaving the profession faster than they are entering it. Operating on an uneven playing field, their professional status may come under threat if anything goes wrong, and they may be held professionally accountable for informed decisions made by their clients.
A chronic midwife shortage exists in Australian hospitals, partly due to the lower job satisfaction than may be found among midwives providing one-on-one care at home and in birth centres. Sarah Buckley identifies “a lack of systems for peer support and supervision, and difficult liaison and professional relationships with hospitals”.
In 2001, the future of the independent midwifery community in Australia was jeopardised by the withdrawal of professional indemnity cover by Guild Insurance, the only company offering a policy for midwives. The argument it gave was that Australia’s midwives had become too small a group for collective coverage to be provided.
Six years later, this crisis still remains unresolved. In some states and territories it is illegal for midwives to practise without insurance. Difficulties with insurance are not limited to Australia; earlier this year, insurance for independent midwives was withdrawn in Ireland for the same reason.
The Australian College of Midwives describes midwifery as ‘political’, and it is increasingly evident that further lobbying is needed. In 2002, Maternity Coalition launched the National Maternity Action Plan, a reform document that makes a set of key recommendations, including the need for community-based midwifery care to be made available nationwide via the public health system. The Plan has been endorsed by all of Australia’s consumer, midwife and nursing groups.
Maternity Coalition sees a midwifery-focused maternity system as better value for money than an expensive, high-technology, and high-intervention approach. Taxpayers are funding high-tech hospital birth practices through Medicare rebates covering interventions and the 30% private health insurance rebate. The high cost of private specialist obstetric care is publicly subsidised on several levels. This money spent on over-servicing could be more effectively spend on training, supporting and insuring midwives.
The major concerns of Maternity Coalition include diminishing birthing services in rural areas, a lack of midwifery options, the high caesarean rate, and rapidly increasing costs in the public health system.
So what are politicians doing? If spent elsewhere, the $34- and $31-billion tax cuts recently promised by the major parties could fund a world-class maternity system where women are not left to miscarry in hospital toilets, as recently occurred in Sydney. More encouragingly, Labor has recently announced plans to extend Medicare rebates for midwifery care if it wins the election. A new party known as What Women Want was launched in Brisbane in June, and is fielding Senate candidates in every state. One important area of policy is an improvement in maternity services.
Given unbiased information, full freedom to choose and access to a midwife, far more Australian women would choose a natural birth at home or in a birth centre than the few who do at present. Ultimately, choice is the primary issue, and if Australia’s midwife community completely disappears, that choice will be taken away.
Australian Society of Independent Midwives: www.australiansocietyofindependentmidwives.com
Home Birth Australia: www.homebirthaustralia.org
Home Midwifery Association (QLD): www.homebirth.org.au
Joyous Birth: www.joyousbirth.info
Acknowledgements to Dr. Sarah J. Buckley for her valuable input. Sarah is author of Gentle Birth, Gentle Mothering: The wisdom and science of gentle choices in pregnancy, birth, and parenting, One Moon Press, Brisbane 2005
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