How to Guarantee Yourself the BEST MATERNITY CARE

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].

These figures can't be explained by saying that pregnancies/births in the private health sector are more high risk - because that isn't the case. In fact, really high risk private patients may end up delivering in the public sector due to the public sector being equipped with services and facilities (such as NICUs) that the private sector doesn't have. So what these figures are showing us are the differences in practice between private obstetric care and public care. And the difference is more intervention, but not always with indication for intervention. And this increase in intervention does not result in better outcomes for mums and babies. In fact, this study compared low-risk pregnancy care with MLC, standard public care and private care. The results showed adverse outcomes such as episiotomy or severe perineal trauma was highest in the public sector (2%) vs private care (1.4%) and lowest rates were MLC (1.2%); low APGAR scores (a measure of a baby's transition to life on the outside) NICU admissions, and neonatal death highest in the public sector, then the private sector, and lowest in MLC. And given the higher risk profile of the public hospital - this could explain the rates of adverse outcomes being higher than private care.

Why do we care though, about more caesareans, more episiotomies, more epidurals? Well, because these things are generally more risky to mums and babies. They can slow recovery, impact breastfeeding, cause readmission to hospital (for things like infection), and impact on the baby (through separation, NICU admission, less breastfeeding...). You can also read here about the complexity of the next birth after having a caesarean section, and why avoiding a caesarean in the first place is a good thing.

Ok, so now this just got bloody confusing! You might pay money to access a particular type of care (private), but might have less chance of getting what you want (e.g. a normal birth), or get free (public) care and have more chance of what you don’t want (e.g. unmedicated birth). How do you make sense of this? How do you make a decision that SUITS you? Because for all the research in the world, none of it matters if it doesn’t feel the right thing for you and your baby.

Well, this is where it’s important to know yourself and your wishes when it comes to things. I call this “birth preferences”. Not the birth plan – if we could plan our births then that would be fantastic. Preferences is a nicer way of saying ‘I’m informed about this, and this is what I’d like to happen in the case of x, y and z…but if a and b occur, then I would like this”. If you have a fair idea of where you lie on the spectrum of things, then you’ll have an idea of what’s best for you. If you are low risk and would like the best chance of great outcomes, continuity of midwifery care in the public system is for you. If you want to have a fair bit of choice in having interventions such as induction, epidural, planned caesarean section (and you're not convinced so far on the risks associated with these!) and so on, then care with a private obstetrician might be best for you. 

And what if you’re high risk? Well, public hospitals are staffed by some of the best obstetricians, which means you will still have the experts having a say in your care, you just might not get the continuity of care that comes with a private obstetrician. But what if you want a private obstetrician, but also to know your midwife who will care for you at the birth (yep – the obstetrician is only going to be there sporadically during your labour - and may miss the birth altogether if it's quick!); or what if you are booked in the public system but can’t get into a MLC or ‘know your midwife’ program? Well, I still have a solution for you! A student midwife (or, pay for a privately practising midwife)! There are thousands of next generation student midwives in Australia, and if the hospital you are booked at has a reasonable number of births per year, then chances are you will run into at least one student midwife anyway! Why not pair up with one in pregnancy and enjoy the benefits of continuity of care?

There are very stringent guidelines around a student midwife’s clinical practice: they must practice supervised, and they must achieve certain competencies and minimum numbers of practice experiences (for example, they must facilitate 30 normal births during their course). One element of their training is to practice continuity of care, and they must follow at least 10 women through pregnancy, birth and afterwards (supervised by midwives and obstetricians). So you are getting your own midwife-in-the-making, who is essentially on-call for you, for free, and you can dictate how much ‘hands-on’ you’d like them to have as well. If this sounds like a good idea, I recommend contacting a Midwifery teacher at a university near you or your local hospital, to get in touch with a student midwife. Oh, and this study showed that women who are paired with student midwives enjoy the experience (and there are other studies that support this)!

I hope this has been a helpful read. Please share the love by sending this post to a supermum or supermum-to-be, who might benefit from this article. And I would love to hear your thoughts and experiences in the comments below!

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[1] Sandall J, Soltani H, Gates S,Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub5

[2] Conesa Ferrer Ma B, Canteras Jordana M, Ballesteros Meseguer C, et al. Comparative study analysing women’s childbirth satisfaction and obstetric outcomes across two different models of maternity care. BMJ Open 2016;6: e011362. doi:10.1136/ bmjopen-2016-011362

[3] Dahlen HG, Tracy S, Tracy M, et al. Rates of obstetric intervention and associated perinatal mortality and morbidity among low-risk women giving birth in private and public hospitals in NSW (2000–2008): a linked data population-based cohort study. BMJ Open 2014;4:e004551. doi:10.113

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