A midwife friend said recently ‘childbirth is consistent across time and cultures’, a simple truth lost in the frenzy of western society. It seems we have forgotten that in the majority of cases, childbirth is usually a straightforward event with the highly predictable outcome of a healthy mother and baby.
For all appearances, women have never had better access to maternity care or been as safe during their childbearing years. At least this is so if they live within a reasonable distance of hospitals with maternity capacity and don’t object to production line services.
They no longer need to bear a child with abnormalities because there is a range of diagnostic tests that identify conditions that may or may not be life threatening, in some cases are treatable perhaps even in utero, or at the very least can be prepared for. Termination of pregnancies for severe or terminal genetic abnormalities is readily available, and advised. This contributes to maintaining low perinatal mortality in Australia.
If a woman has trouble conceiving, reproductive technologies can assist although with a relatively low rate of success and due to cost are only accessible to those who have the means.
There is no need to encounter the pain of labour. Epidural anaesthesia is encouraged, despite the fact that it contributes to higher levels of caesarean, vacuum or forceps operative deliveries. Women can choose to give birth by caesarean surgery without clinical indications even being present. Caesarean birth is promoted by obstetricians as being safe, if not safer than normal childbirth.
None of these medical treatments are without risk and come at a cost, some physical, some emotional and all at either taxpayer or individual expense, whether in the public or private health system. Judicious use, based on individual need is paramount.
When it comes to maternity services, it appears though that no expense is spared to provide what is considered the best. As a result, medicalised childbirth has largely replaced the low tech, low intervention approach to a normal physiological event that has indeed been constant over time and across cultures, no more so than in the developed world where the general health of the population is very good. It must be asked – is this situation actually in the best interests of women and babies and an effective use of our workforce and finite health dollars? Or, are other vested interests at play in maintaining the status quo?
Currently, specialist obstetric care is provided as a matter of routine to a high proportion of women, regardless of their health status. There is no conclusive evidence to demonstrate that this level of care contributes to better outcomes than those achieved by midwives supporting normal no-to-low intervention birth, except where a woman or baby is compromised. It is evident that the more highly specialised the carer, the higher the likelihood of intervention in the progress of the pregnancy, labour and birth.
It is also clear that intensive medical surveillance and interventions use high levels of human, technological and monetary resources, and this is costing our health systems dearly. It is also contributing to greater levels of birth trauma and postnatal depression.
Only a minor percentage, estimated at around 20 per cent, of the 250 000 women who give birth annually in Australia, should require the expertise of specialist obstetricians to achieve the best possible outcome for their individual circumstances. The national caesarean surgery rate alone, however, is now over 27 per cent (up from 16 per cent in the late 1980s, and 19 per cent in the mid 1990s), without factoring in vacuum or forceps deliveries. It is not surprising then that maternity care accounts for the most number of hospital bed days and is significantly contributing to a blow out in the Medicare safety net. This occurs in an environment where ‘early discharge’ is taken as literally as possible, with mothers leaving hospital on day two or three post birth compared with an average eight to ten day hospital stay two decades ago. Most importantly, these figures indicate that something is seriously askew in maternity services.
Maternity care is one area of health services that would be well served by a determined effort to reduce the level of specialist care provided to women. Increasing reliance on the skills of midwives to provide whole episodes of primary care for healthy women has been proven to result in a greater level of normal births and a reduction in use of anaesthetic pain control, which is often responsible for a cascade of further medical interventions.
Midwives as first level providers are not as radical a suggestion as some obstetricians in Australia argue. In many demographically similar countries – the United Kingdom, the Netherlands, Canada, and New Zealand for example – primary midwifery care is an integral component of maternity services with the midwifery workforce contributing up to 80 per cent responsibility for primary care throughout the childbearing continuum.
Midwives are experts in normal pregnancy and birth, able to detect conditions that may require specialist interventions, and are committed to the principle that childbirth is a usually a straightforward event.
In recent decades, their skills have been relegated to handmaiden status, especially when they work in environments where they are required to adhere to standardised and automated maternity care. In most hospital settings (where over 95 per cent of births occur), midwives are limited in the capacity to provide the full scope of their practice, because they act in an assistant capacity to medical practitioners.
One thing is certain: women have the greatest possible chance of a spontaneous normal birth when they feel supported, have control over the environment in which they are giving birth, and trust themselves and the people who are present. Even with all these factors, there are no guarantees, because like all things, childbirth does not follow a prescriptive pattern. Nonetheless, a known caregiver and a safe environment are the greatest support to women during the intimacy of childbirth.
The greatest indicator of this type of care is found in the Netherlands. There is no question that Dutch culture has a firmly imbedded attitude to childbirth as a normal event in the cycle of life.
All pregnant women in the Netherlands consult with midwives, who most usually work in group practices, set up in a similar fashion to general practitioner surgeries. One third of Dutch women birth their babies at home. Only 14 per cent have caesarean surgery – indicating that only those women who require surgical intervention to achieve their best possible outcome are doing so. The remaining women have up to a 24-hour hospital stay, longer if needed.
Interventions across the childbearing episode are lower than in other similar countries. Epidural usage is minimal as childbirth is undertaken as a matter of fact and of life. Midwives account for the primary care of over 80 per cent of women and this is not considered as anything but normal.
Similarly, in New Zealand, dramatic structural changes to maternity services now see over 75 per cent of women cared for by midwives compared with fewer than 10 per cent in 1990 when the changes were implemented. There is also a decline in spending for maternity care.
It is not a quantum leap to propose that Australian women could have the same access to similar maternity services. Existing hospital services could be reconfigured to provide both hospital and community antenatal and postnatal care and birth centre type births, with a full time equivalent midwife providing primary care to between thirty five to forty women per year. It would be cheaper, achieve the same results, would be better for women and babies and would appropriately use the varying skills of health professionals.
This approach to providing women with good birth care has been increasingly advocated across Australia in the past few years. The call has mainly come from women and midwives in response to an alarming rise in a range of interventions, the lack of real choice, and the stripping away of women’s autonomy in childbirth.
Maternity services need to embrace the full extent of woman centred care, by honouring women’s right to safe, respectful and non-judgmental professional attention. The guiding principles of maternity services should always be that women are usually healthy, know their bodies and their strengths and weaknesses. Midwives have the knowledge and capacity to develop a relationship with each individual and support her unique birth journey. Care provided by a midwife is an extraordinary opportunity for women to be empowered in their birth, and in themselves, creating the best possible start to parenting. Of all the reforms needed in our health system, maternity services are the ones most readily able to be restructured at minimal expense. As ably demonstrated by the New Zealand experience, all that is needed is the will of governments to achieve this goal.