“Childbirth is absolutely a human rights issue. When you are making decisions about somebody's body, their personal autonomy, their right to decide the circumstances in which they live, breathe, and function, you have to abide by those fundamental human rights. And what we are seeing in pregnancy and childbirth is women all around the world are reporting that as soon as they become pregnant, there is a presumption that those rights don’t apply to them.”
– Bashi Hazard
Speaking directly to the Australian context, we have biasedly more access to some models of care than others. Not only in pregnancy, birth, and postpartum but within our healthcare system as a whole. Speaking directly to pregnancy, birth, and postpartum, the model of care you choose deeply influences the type of experience that is easily accessible to you.
I say 'easily', because as many would know if you have birthed or supported birth, there can often be a fight to be heard, seen, and held in this time depending on where you are birthing. As the trained psychology student I am, I have delved into research to provide numbers and statistics for those who relate most to this type of information. If that is not you, bypass the numbers but please see their place in mirroring the current culture we live in and the seriousness of understanding it all for your own journey.
**PSA: many who read this may have had a great, positive, and caring experience in public or private OB settings (I myself have supported many positive and empowering public hospital births). Please know I am not demonizing these models of care, but urging women and couples to consider the birth culture within Australia and how that translates to our models of care, care providers, and care provider beliefs around birth, to then understand how it directly impacts your experience.
What models of care do we have?
To keep it simple:
Public hospital maternity care
Shared care (often with a GP and the hospital)
Midwifery group practice/Caseload (MGP)
Private obstetric care (OB)
Private midwifery care
Read more information about each model (as well as some others that are a lot less common) here: Maternity models of care in Australia, 2023, Major model category definitions - Australian Institute of Health and Welfare (aihw.gov.au)
The availability of such models in 2023 goes:
41% are within public hospital maternity care
15% shared care
14% MGP caseload care
11% private OB care
With over one-third of models having no continuity of carer in any stage of the maternity period
35% having continuity of carer for some part of the maternity period (only antenatal or postpartum) and
29% having continuity of carer through the whole maternity period (highest numbers found in QLD, SA and ACT). This 29% includes OB care, private midwifery care, and MGP caseload care
Why does continuity of care matter?
Ongoing research has highlighted the importance of continuity of care not only for maternal and baby health outcomes but the satisfaction mothers and fathers/partners are experiencing in their pregnancy, birth and postpartum care. Research aside, it also just makes so much sense that those we know we are more comfortable with during such a vulnerable and intimate life event.
A Cochrane review of 26 studies from 17 countries involving more than 15000 women showed that women who received continuous support during childbirth are:
more likely to give birth spontaneously (vaginally with neither ventouse, forceps or cesarean)
less likely to use pain relief
less likely to have a cesarean
more likely to be satisfied with their birth
more likely to have shorter labours
babies are less likely to have a low 5 minute apgar score
Amazing.... we know that continuity of care is the highest level of care for pregnant and birthing women. In the 29% stated above, 2023 saw continuity of care being offered for the whole maternity period only in OB care, private midwifery care and MGP caseload care.
OB care and MGP caseload care are hospital-based models of care, with private midwifery care having the option of exclusive in-home care without the use of the hospital setting at all.
In 2021:
97% of Australian births took place in hospitals in conventional labour wards
75% did so in public hospitals
2% birthed in birth centres
0.5% birthed at home
0.7% in other settings (such as born before arrival)
Let's take a break from numbers for a quick sec and consider what this says about the birth culture in Australia: 97% of Australian women are accessing care in hospitals. Women's choices to do so are unique and individualised, some may feel safest in a hospital setting, may have high-risk pregnancies, and/or the financial component of public healthcare plays a big part in women's accessibility to models of care in pregnancy, birth and postpartum.
75% of women are accessing care via public healthcare, which arguably is a considerably lower (upfront) financial investment than private midwifery care or OB care.
What we can now start asking is: why is the hospital seen as the safest place to birth? so much so that public funding is tunneled to this model of care which directly impacts women's spread of choice in their pregnancy, birth, and postpartum care?
Let's now look at birth outcomes for place of birth and model of care in the current years in Australia
From an inexhaustive list of Australian research regarding place of birth:
regardless of risk status, planned home birth was associated with significantly lower rates of all obstetric interventions and higher rates of spontaneous vaginal birth
low-risk women had similar rates of perinatal mortality irrespective of birthplace, however, overall composite perinatal and maternal morbidities were significantly lower for those planning a home birth
even those planning a homebirth who then transferred to the hospital saw higher rates of vaginal birth and lower rates of neonatal NICU admission when compared to planned hospital births
compared with planned hospital births, the odds of normal (physiological) labour and birth were over twice as high in planned birth centre births and nearly six times as high in planned home births
no statistically significant differences have been found in the proportion of intrapartum stillbirths or early or late neonatal deaths between birth centre births, hospital births and home births
From an inexhaustive list of Australian research regarding the care provider models:
women in public midwifery continuity care:
are less likely to have a scheduled caesarean,
are more likely to have an unassisted vaginal birth,
experience freedom of mobility during labour,
experience informed consent processes for inducing labour, vaginal examinations, fetal monitoring and receiving syntocinon
and report the highest quality intrapersonal care
they also have fewer vaginal examinations,
less likely to have an epidural
lower odds of perineal trauma requiring sutures
lower anxiety after the birth
shorter postpartum hospital stays
and higher odds of a home postpartum care visit
women in private obstetric care are:
more likely to have their labour induced
more likely to have a scheduled caesarean birth
more likely to experience informed consent processes for caesarean
report high-quality interpersonal care
but less likely to experience unassisted vaginal birth
less likely to experience informed consent for syntocinon to birth their placenta
spontaneous onset of labour and an unassisted vaginal birth likelihood:
58.5% in MGP
48.2% for standard hospital care
30.8% for private OB care
Going back to the start of this blog post: only 14% of Australian models of care in 2023 were MGP caseload care. This is based on the availability of midwives and programs in hospitals around Australia that implement such care. This means that the possibility for women to access this care (which has the highest likelihood of spontaneous labour and unassisted vaginal birth) is considerably lower than say the 41% which makes up public hospital care.
Here's a snapshot of what models of care were used in Australia in 2023:
I often come to the point now of asking myself: okay, rates of intervention are higher in private OB care and public hospital maternity care, but what does that really mean for the woman and her experience?
I guess, that is totally up to the woman and how she perceives her experience, her value on physiological birth, or whether she feels safer utilizing medical intervention in her labour. If this is the case though, I would highly recommend asking yourself why you feel safer using medical intervention, and whether this is rooted in the cultural conditioning around birth or if it is based on unique and personal circumstances. If it is the latter, there is still an opportunity to go deeper into this and understand more of any fear you hold around birth.
What does the research say?
Over one-third of women experience psychological birth trauma, and this can impact not only the mental health of the mother but the family relationships, including bonding with the child.
4 themes have been identified in women's descriptions of what they found traumatising in their births:
postpartum women with indications of perinatal PTSD symptoms are found to have 44 times higher odds of screening positive for depression
depression, anxiety and perinatal PTSD are each independent risk factors for one another
evidence is strong that the mode of birth is not associated with the risk of postnatal depression
when women perceived supportive caregiving from their childbirth providers, their long term memories of the birth experience were positive irrespective of complicated or difficult birth events
a significant association has been found between women's postnatal perspective of their birth experience and postnatal depression
So, what do women want in their maternity care to avoid the outcomes described above?
A systematic review of 59 studies based in Australia from 2012 to 2023 found that four themes developed. Women want:
continuity of care
to be seen and heard
to be and feel safe
to be enabled in their experience
= what model of care are we most likely to see these themes?
Here's where I impart another PSA: THIS IS NOT MIDWIVES OR BIRTHING WOMENS FAULTS
Research shows that less than a third of Australian midwives report their workplace as a positive culture, that they feel disengaged and unsupported, and have the inability to use all of their midwifery knowledge in medically-dominated environments.
The crux of this post is to encourage you to look at the culture in which you are birthing, utilise the research as a mirror of that culture, and question where you would like to place your resources in your model of care should you have the freedom to do so, to get the experience you are wanting. Almost all of us immediately assume that 1) we will birth in a hospital and 2) in a public maternity hospital because we are rarely shown or encouraged to access the other options available. Beyond this, we assume that private health means better care because it comes at a cost, and money is the exchange of value in our modern world.
If the care you choose to go with (whether by what's available or personal choice) is one that is not conducive to positive birth outcomes, what you can then do is use this information to educate yourself and become rooted in advocating for yourself and your baby.
I will go further into how you might make this decision and what can follow in the next post. I've gabbed on for quite awhile here. See below for all research used:
Maternity models of care in Australia, 2023, How many models of care are there? - Australian Institute of Health and Welfare (aihw.gov.au)
Maternity models of care in Australia, 2023, Major model category definitions - Australian Institute of Health and Welfare (aihw.gov.au)
Planned private homebirth in Victoria 2000–2015: a retrospective cohort study of Victorian perinatal data | BMC Pregnancy and Childbirth | Full Text (biomedcentral.com)
Mapping the trajectories for women and their babies from births planned at home, in a birth centre or in a hospital in New South Wales, Australia, between 2000 and 2012 | BMC Pregnancy and Childbirth | Full Text (biomedcentral.com)
Women’s descriptions of childbirth trauma relating to care provider actions and interactions | BMC Pregnancy and Childbirth | Full Text (biomedcentral.com)
Co-occurrence of depression, anxiety, and perinatal posttraumatic stress in postpartum persons | BMC Pregnancy and Childbirth | Full Text (biomedcentral.com)
A direct comparison of patient-reported outcomes and experiences in alternative models of maternity care in Queensland, Australia - PMC (nih.gov)
Caseload midwifery compared to standard or private obstetric care for first time mothers in a public teaching hospital in Australia: a cross sectional study of cost and birth outcomes | BMC Pregnancy and Childbirth | Full Text (biomedcentral.com)
With a special interest in natural fertility, conscious conception, and conscious relating through starting a family, I offer birth support and related services to encourage more depth and awareness in your journey. I educate on the menstrual cycle and encourage women to reawaken their confidence and trust in their bodies, and show an understanding of how all of these experiences are interrelated and must be considered on your journey to starting a family.
I share similar information regularly on my social media. Please follow to keep updated, and contact me if you'd like to talk more about this divine time of preparing for your spirit baby.
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