Finding out you are pregnant might be super exciting for most of us, but then a healthy dose of reality usually hits soon after. You’re going to have a completely dependent human being in a few months. Your body is going to change. There’s going to be pain, blood, poo, vomit, wee…and not necessary just from the baby! Having great care in pregnancy and beyond is essential for support, education, and the best outcomes for mums and babies. There is a common saying about many things in life – that you get what you pay for – and many people believe that this also applies to maternity care, and they elect to have a private obstetrician and birth in a private hospital, and are thousands of dollars out of pocket. But health outcomes don’t just come down to the amount of money spent – support, education, facilities, infrastructure, satisfaction…these and more are all very important in the whole picture. And amount of money spent doesn’t equal best practice always, either. You just need to look at individual intervention rates and so on to see that obstetric practices differ greatly from obstetrician to obstetrician. That’s why in Melbourne we have one brilliant doctor nicknamed ‘Vaginal Lionel’ (I’ll let you guess why) – his philosophies and practices around vaginal birth and breech birth are different to some others, and he enjoys success and a good obstetric reputation because of this.

There are many things that influence a woman’s decision regarding her maternity care. For some women, it might be convenience or location – the hospital is very near to work or home. For others, it might be the recommendation of friends and family, a financial decision or access to particular services (e.g. waterbirth, NICU). This article will have a look at the research around maternity care options, which might help you make a decision on what will best suit you.

The best maternity care

When considering the ‘best’ maternity care – it’s important to think about what ‘best’ means. Is it

• The healthiest mums and bubs/best outcomes;

• The lowest intervention rates/high normal birth rates;

• The cheapest option;

• The option with the highest satisfaction levels; or

• Something else?

Well, unless stated, this article discusses the evidence in relation to low risk pregnancies. This means that mum and bub are at low risk of complications occurring during pregnancy, birth and the postnatal period – and this is the vast majority of pregnant women. High risk pregnancies need specialist, individualised care, so it’s impossible to do a generalised post about this.

What if I told you that there is one option of care that could achieve all of those bullet points above?! Well, it’s true! And this option is midwifery-led continuity of care [MLC]. This means a midwife is the main health professional caring for a woman during pregnancy, birth and afterwards, and hence the woman knows her midwife/midwives who will support her through her experience. It’s also usually free, as MLC is accessed through the public health care system.

In 2016, this systematic review (this is the highest level of evidence that exists, essentially combines all relevant studies of a topic to end up with a huge sample size/amount of data) of MLC looked at 15 studies of 17,674 women comparing MLC with other models of care. The results showed that women in this model of care were less likely to experience instrumental birth (forceps/vacuum birth), preterm birth, stillbirth or neonatal death, epidural analgesia, episiotomy, pharmacological pain relief and artificial rupturing of membranes. Women were more likely to have normal births and have a known midwife at birth, and were more satisfied with their care[1]. Sounds like a pretty good option to me! Since this systematic review was published, this study was released showing similar results – but also showed women in MLC models of care were less likely to have an induction of labour, episiotomy, perineal trauma and had shorter labours (woo hoo!) and were more likely to have natural labours and births and no pain relief during labour[2]  – compared to the women in a medicalised model. No pain relief in labour may reflect that more mums prefer not to use pain relief in this group, however it also is pretty indicative of just how good the support of a known midwife is in labour, that many mums don't need medicated pain relief! It is pretty understandable that another finding was higher satisfaction levels in the mums who had MLC. There’s also this study, this study, this study, this study, and many more with similar findings to those listed above! This study, although very small, also showed positive effects of MLC on women with an intense fear of childbirth.

So how do we know it’s the MLC part of the care package that is related to such good outcomes, and not just because the same person is caring for each mum? Well, because the studies compared MLC with other models of care, including other continuity models such as those in the private health care sector with a known obstetrician. This is still a great care option, and many women do have their care with a private obstetrician, but the criticisms of this model of care are the high cost to women (often thousands of dollars) and high intervention rates in the private sector (more later). However, this government review of maternity services identifies any continuity of care model as a key element of quality maternity care – in other words, great maternity care must include continuity of care. Women want this type of care, and that is why some women choose private obstetricians – because they want to have the same person care for them through their experience, and they’re happy to pay for the privilege. Unfortunately, though, continuity of carer is not accessible for everyone. For some, the cost associated with private obstetric/private midwifery care is too great. And whilst MLC is available in the public sector, not all hospitals have it as an option, and those that do might only offer it to a small percentage of women who birth there. Here lies another issue in our health care system – lack of funding and equity of access throughout the country.

So what’s wrong with private care though, if you can afford it, and guarantee yourself the continuity of care by a chosen obstetrician? Well, as mentioned earlier, one of the criticisms of the private health care system is the high rates of intervention often seen, without a corresponding increase in pregnancy/birth risk factors. So the women in the private sector are generally healthier, with low-risk pregnancies, but have higher rates of interventions. A landmark study in 2014 outlined exactly this, and looked at the births of almost 700,000 low-risk birthing women in NSW over an 8 year period. The differences between public and private are stark[3].