Episode 48 - Australian Mothers and Babies stats
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD. And each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth and postpartum journey. Welcome everybody to today's episode of the Great Birth Rebellion podcast. Today I'm here with Kirsten Small, and if you've been listening to the podcast for any length of time, you will have heard Kirsten on the podcast before. She's a great friend of mine, and we're going to talk about the Mothers and Babies Report. That's what it's called, isn't it? I always get it wrong, Australia's Mothers and Babies.
Kirsten:
[0:46] Or Women and Babies, one of those.
Mel:
[0:49] One of those, yeah. I always get it wrong because I call women women. And I don't like to pigeonhole them into just being mothers.
Kirsten:
[0:58] Because we're much more complex beasts than that, we mothers.
Mel:
[1:02] But the Australian Institute of Health and Welfare of the Australian government likes to call us Australia's mothers and babies and every year they release the stats on how women are faring and how babies are faring in their pregnancy, birth and postpartum time. The stats are always two years behind. So these stats that Kirsten and I are going to be talking about today are released in 2024, but they're from 2022. You know, we did this last year on the podcast, did the stats. I think it's important to see where we're up to as a nation and what women can come to expect from our maternity care system. And sometimes statistics and reports can be a little bit dry and so when I invited Kirsten on the podcast today to do this topic with me I said to her you know I want to play a drinking game And she's like, I'm listening. Also, we needed to do this in the afternoon because if we played a drinking game in the morning, there goes the rest of the day. So we're currently recording at the very festive time of 4 p.m. my time, 3 p.m. Kirsten's time on a Friday afternoon. So thank you, everybody, for giving us this opportunity. It's close to Christmas. We thought, why not? look
Kirsten:
[2:28] We all have that one friend who can talk us into doing just about anything ridiculous and for me yes.
Mel:
[2:35] And i did as i was talking to kirsten about a drinking game around the women's and babies statistics it occurred to me that there will be points in this podcast where drinking is of very poor taste so i just want to put out there that we are not drinking in celebration we're drinking out of sheer distress and um basically some of the stats will have driven us to drink so we're only going to drink if things are getting worse we can't drink every single statistic if they're getting better i think we'll just give it a good old flat so anyway we're not going to get too plastered hopefully by the end of this unless the stats are really bad in which case you know the editing is going to be fun okay hopefully we stay coherent until the end what
Kirsten:
[3:30] Are you drinking mel.
Mel:
[3:31] What am i drinking okay dan my husband's made me a whiskey sour and i was just saying to kirsten that i am actually recovering from a cold which you might be able to hear and so I ordered from the kitchen my kitchen something medicinal and so we've got whiskey that was made by my friend and some lemon juice it's got organic maple syrup which is high in nutrients so that's fine and egg from our chickens so I feel like this is a whole food and very nourishing and fine to be drinking while recovering from a cold
Kirsten:
[4:08] Absolutely. I've got a dry martini.
Mel:
[4:12] A cocktail glass even.
Kirsten:
[4:14] Oh, yeah. And with aviation gin because Ryan Reynolds is quite cute and he owns aviation. So there we go.
Mel:
[4:22] See, Ryan Reynolds owns aviation gin. We haven't got any money for that in terms of an endorsement. So I might just do a call out and let them know you've mentioned them. Merch.
Kirsten:
[4:34] We can get some merch.
Mel:
[4:36] Yeah, they'll send us a few dollars for just, if we're calling out brands, my friend is the owner of Brew Mountains. It's a microbrewery here in the Blue Mountains called Brew Mountains. So good. He makes the best beer. Shout out to Craig. We're drinking his whiskey. Okay. We're going to get started on the stats. So just to make it clear, if the stats got better, they're going to get a good old cheer and a bit of a clap. If they got worse, you've got to take a sip. don't drink the whole thing in like we're not it's not that kind of drinking game like no have a sip babe because we've
Kirsten:
[5:12] Got to get through.
Mel:
[5:13] Correct so I want to kick off by saying that Australia is a very physically safe place to have a baby and when I say physically safe I mean in terms of the raw outcomes of the number of mums and babies who don't make it and don't survive birth is relatively few when you compare it to other countries. I don't want you to come to this episode and say like Mel and Kirsten are just going to absolutely dump on the amazing safety record that Australia has for women and babies and But we also can't be too complacent and, you know, not dead is not the only marker that we should be measuring and understanding with regards to the quality of a health service. So this report only reports on very few hard statistical facts and outcomes. It doesn't look at women's satisfaction level, for example, birth trauma outcomes. It just says like how many people had a cesarean. How many people had an episiotomy? Is it more or less than last time we checked? How many internatal appointments are women getting? It's like really basic stats, but it does give us a snapshot into what's going on in the healthcare system and maybe what areas to target. And this is certainly what some policymakers and government departments will use to gauge how well we're doing in providing maternity care to women.
Kirsten:
[6:43] My saying is that what gets counted is what comes to count in the sense that once people have decided which things to collect statistics on, because other things get left off the list, as you pointed out, measures of women's satisfaction or their mental health, not collected routinely in maternity services. So the things that big organisations like the Australian Institute of Health and Welfare decide to count become the things that matter to governments and that matter to health services and that matter to funders and to professional bodies. You know, there's no doubt that the things that they've chosen are important, but they aren't the only things that are important in healthcare.
Mel:
[7:29] Definitely not a full picture. So let's have a look. Let's have a look. Drinks ready. I keep looking at my drink thinking I want to have a sip and I'm like, don't start yet. So pace yourself. So one sip if things are getting worse and not too much because I need you to stay upright for the whole episode. So some general stats. The number of mothers who gave birth, 2022, in Australia, 293,435 women who gave birth to 297,725 babies. Well done for you all,
Kirsten:
[8:04] You amazing women out there who had a baby.
Mel:
[8:07] Generally, it hovers around that 300,000 babies born a year in Australia. And you'll see if for anybody who's really paying attention, there were more babies than mothers, of course, because that accounts for mums who are having twins and multiple babies.
Kirsten:
[8:23] Or the occasional woman who goes, oops, and manages to have two babies within a 12-month period.
Mel:
[8:29] Yes, of course. I didn't think of those babies. And in, let's, oh gosh, I didn't even compare this, but we're going to have to drink after this. So in 2022, 41% of mothers who gave birth had a spontaneous labor. And spontaneous labor means they went into labor on their own without having their waters broken or their labor induced with things like syntocin on or Foley's catheters or Cervagel, Cervidil gel, any means of induction. So 41%, 33% had their labor induced by one of those methods I just described. And 26% had no labor, which doesn't mean they're still pregnant what that means is that they had an elective cesarean section for whatever reason either they chose or their care provider chose or they required it medically
Kirsten:
[9:30] And or labor started as opposed to because there are other cesarean sections in the list that happened once labor was underway and the induction the the induction count is it still underestimates slightly because there's some stuff that goes on in maternity services that are the inductions that you do that aren't inductions. So all of those women who had stretch and sweep, some were told that this had just helped to avoid being induced without actually having a conversation about the fact that anything that you're doing that's designed to make labour start, well, that's called an induction.
Mel:
[10:04] Exactly. But it's still a form of induction. So bottoms up to that one. That's pretty sad. so between I'm going to go right back to 2010 between 2010 and 2022 which is the current stats the rate of no labor has steadily increased from 19 percent in 2010 to 26 percent basically mourning the the fact that less than 50 percent of women get to go into labor all their own Have a drink. Oh, that's a good whiskey sour. He's done a good job. Okay, I had two sips because that was more than one stat. All right. And then the next thing I've written down my piece of paper is it says, over time, the proportion of women who have had vaginal non-instrumental births has decreased and the proportion of women who have had cesarean births has increased. So vaginal birth assisted by vacuum or forceps has remained relatively stable. Kirsten, I'm reading this sentence. The proportion of women who had a vaginal non-instrumental birth has decreased. Right. Just a plain vaginal spontaneous birth without instruments.
Kirsten:
[11:27] Yes. Though I think I'm actually okay with calling it, I call it a non-instrumental vaginal birth because the word spontaneous becomes a little bit meaningless when you're looking at women whose labour was induced and whose labour was augmented and who had purple power pushing. It's not really spontaneous. So it's not really accurate terminology. It's a baby that came out of the vagina without somebody putting forceps or a vacuum cup on top of its head, but it's not necessarily arriving spontaneously.
Mel:
[12:06] And they would have also had an episiotomy that would also be counted in there.
Kirsten:
[12:11] Much more likely to, yes.
Mel:
[12:14] Yes. So 49% of women had a non-instrumental vaginal birth in 2022 compared with 56% in 2010. So less than, well,
Kirsten:
[12:28] Half. Less than half.
Mel:
[12:30] Yeah by one percent had a non-instrumental vaginal birth which meant that basically no one gave them a cesarean section or their babies weren't born with forceps or vacuum but they could have had an episiotomy and an induction and active pushing and every other intervention it just meant that their baby came out of their vagina without hands-on sort of instrumental help okay I'm having Yeah,
Kirsten:
[13:00] That's, I agree. Quite sad that, you know, something that's a physiological function, if you just sit tight and do nothing, it's not really normal anymore. It's less than 50% of the population. It's becoming an exception rather than the rule.
Mel:
[13:16] Yes. Now, the next thing is 6.9% of women had a vaginal birth assisted by vacuum, which is actually less than 2010, but the force of rate has gone up and the caesarean section rate has gone up. So do you care to explain potentially why the vacuum rate might have gone down compared to 2010?
Kirsten:
[13:45] I do know that the balance between the two procedures is it's generally a matter of obstetricians' preference and their exposure during trainings. When I was learning my art as an obstetrician, I worked under Aldo Vacker, who was the guru of vacuum extraction. And so we were taught to do very good and safe and effective vacuum births and not so much exposure to forceps. So it became my preferred approach, though I attempted to maintain skills across both. And I just wonder if there's maybe no one championing vacuum extraction quite the way that used to happen and so people are losing skill set particularly with the move to plastic cups I just wonder whether the equipment's not quite as well designed as it was when we had a range of different options of different kinds of cups to use for vacuum extraction than what's available now.
Mel:
[14:54] Because, I mean, there is rules about how many times the cup can pop off before you'll re-attempt. The other thing I wonder is I've noticed the gradual de-skilling of obstetricians, unfortunately, where actually they are less capable of using forceps, vacuum, manual rotations, breach births, all these things. And I wonder if actually when there's an issue, clinicians are favoring going directly to cesarean section than trying some of these instrumental options.
Kirsten:
[15:27] I suspect that's the case. And there's been a move during my professional lifetime towards doing more attempted instrumental births in operating theatres. When I was learning, we would never call a theatre team in because you were planning on doing a vacuum or forceps, whereas increasingly they're being done in an operating theatre. And it's, you know, just easier to opt out early and go to cesarean section. In some cases, that might well be the appropriate thing to do, but in others, it might be that, you know, there's a lack of commitment to mastering the skills of safe vaginal instrumental use in order to avoid cesarean section. Yeah. knowing what to do when you've got a deflexed, asynclitic, occipital, posterior position, baby. You know, it's not just stick the cup on whatever bits coming first. You've got to work hard to be able to work out exactly what's what, what's where, and get the cup into exactly the right place in order to be able to get the baby to flex its head, correct its asynclitism, and rotate so that it's in an optimal position for birth.
Mel:
[16:44] While the vacuum rate went down, the forcep rate went up and the cesarean section rate went up. So overall, less unassisted births are happening. So we're not making any improvements in terms of the spontaneous rate. Kirsten's shaking her head. Cheers. Ah, okay. It's good whiskey sour. Oh, some good news is there's a decrease in the number of women who are smoking at any time in pregnancy. We are down from 13% in 2011 to 8.3% of pregnant women who smoked through their pregnancy in 2022. So hats off, mamas.
Kirsten:
[17:22] Woohoo, good work.
Mel:
[17:24] I know. That's tough, man, giving up smoking. I watched half my family give up smoking and that is very difficult, but I applaud us as society and women for making that decision. So that's good. We don't have to drink to that.
Mel:
[17:39] I want to talk about gestational age and I know people are thinking, gosh, this would be boring. Why do we need to talk about that? So there's actually been a significant reduction in gestational age from babies who are being induced. So preterm birth is stable. Birth before 37 weeks is stable. There's not a big change, but the rate of women giving birth over 40 weeks is going down, while the induction rate between 37 and 39 weeks is going up. So we're actually bringing babies out earlier. In 2010, about 26, 27% of babies were born at 40 weeks. In 2022, 2022 about 18 percent are born at 40 weeks so 26 or 27 versus 18 percent born at 40 weeks and used to be from 2010 that around 13 or 14 percent of babies were born at 41 weeks now it's around seven or eight percent and there's an and the those numbers have shifted that more babies are being born before 37 and 39 weeks basically what's happening is babies are being induced earlier and earlier compared to 2010.
Mel:
[19:06] And I suspect, oh, I don't want to throw that around too much, but the ARRIVE trial's got some answering to do with regards to...
Kirsten:
[19:15] I suspect it does. The Safer Babies Bundle also has some answering to do in this area because, you know, it's really easy to end up with a risk factor and a recommendation to have a conversation about timing of birth with an obstetrician. And it worries me a bit that we've changed the language here, that we now talk about having conversations about timing of birth. But of course, that kind of implies that you can just press a switch and go, OK, we're going to go into spontaneous labour at 38 weeks and four days. Because that's not what happens. You've got to have an intervention. And that intervention carries some risk with it. You know you have to weigh out the relative advantages and disadvantages of that calling it timing of birth hides the fact that we're actually talking about induction of labor also in some cases cesarean section and making a decision about whether you're doing that at 41 weeks or at 39 weeks.
Mel:
[20:20] I have a recollection of sitting in an etnatal clinic with a client we were going for a consult with an obstetrician and on the same wall there was a big poster about the safety of induction of labor at 39 weeks and it was kind of advertising that as the optimal time to have your baby and then like three posters down it had this diagram of a baby's brain size and function at 36 37 38 39 and 40 and that poster was advocating for waiting till after 40 weeks to give birth because of the massive amount of brain development that happens between each week of gestation. And I was like, who curated this wall that, On one hand, we're kind of advocating for 39-week inductions, and on the other hand, they're going, don't do that. Your baby's got a whole other week of brain growth and brain development to do. It's a bit concerning that babies are being born in earlier gestations, and I wonder what we're doing to our future generation by not giving them those important weeks of brain development.
Kirsten:
[21:33] And there is some fairly sound research that ties gestational age to school outcomes and babies that are born at 41 weeks do better than babies that are born at 40 weeks do better than babies that are born at 39 weeks. You know there's a risk and benefit balance there's you can you can avoid late stillbirth by inducing labour a little bit early but you have to induce a lot of babies to prevent one late stillbirth from happening and you know what does that then mean for the intellectual capacity of Australia's future if you've induced 10,000 babies to prevent one term stillbirth?
Mel:
[22:15] While there has been an increase in induction of labour from you know when stats began so in 1998 there was a 26% rate of induction in 2022 there's a 33% chance that your labour is going to be induced, but that went down from last year. So it was 34. I know. Very good. It was 34% in 2021. And this year it was 33%. But we've just flicked that percentage off to cesarean sections, actually. Oh, I know. I love that. That's the sound, isn't it that
Kirsten:
[22:55] Needs another drink really.
Mel:
[22:56] Damn great all right do it Yeah, so what happened? It's not like we did less inductions and so therefore we had more spontaneous labours. No, we did less inductions and then had more cesarean sections. What have we got next? Oh, this one's interesting. Okay, the main reasons for inducing labour in 2022 were diabetes, 16% of women, pre-labour rupture of membranes, which was 10%. So pre-labor rupture of membranes means your waters break, but you didn't go into labor usually within 18 to 24 hours after they break. Sometimes they'll recommend an induction based on that. And prolonged pregnancy, 10%. And I'm looking at these, and in my practice as a private midwife, there's so many things I want to say about this. Okay.
Kirsten:
[23:55] Go.
Mel:
[23:56] Go. Okay. I haven't had too much of a drink, so my inhibitions are still here, I hope. There's such contention around gestational diabetes diagnosis, number one, that actually the diagnosis of gestational diabetes has gone up because our classification changed. Not necessarily more women are getting diabetes. That may be the case, but we can't really tell.
Kirsten:
[24:21] We shifted the goalposts. And we're screening many people twice now rather than once. So, you know, there's a known false positive rate with the test. So if you test people twice, there's twice as much chance that they'll have a false positive result.
Mel:
[24:38] Yes. And so 16% of inductions are for gestational diabetes. And that's not women who have gestational diabetes and have demonstrated that their diabetes is out of control. That's typically all women who have been diagnosed with gestational diabetes because the policy in hospital is usually to go for induction of labour around 38 or 39 weeks if you've been diagnosed with gestational diabetes, not considering the fact that there's a high false positive rate with these gestational diabetes tests, that the Cochrane Review itself has actually said There's no real evidence-based way that we can determine who has gestational diabetes and who doesn't. There just hasn't been enough research into that. And if you've been diagnosed with gestational diabetes and it's been controlled, so you haven't had wildly out of control blood sugar levels, then actually your body and baby are unaware that you've been given this gestational diabetes diagnosis because you've managed to externally control your blood sugar by what your activities were and what you ate or maybe you never had it in the first place. And so I'm very bothered that gestational diabetes is the number one indicator of induction of labour because it's so fraught.
Kirsten:
[26:02] Yeah. Back in the day, when I was a junior registrar, the number one reason for induction of labour was pre-labour rupture of the membranes. And that was back in the days when we were doing the term PROM trials. And second to that was prolonged pregnancy. So they're still on the list. But diabetes, we didn't routinely screen everyone. The people that we diagnosed with gestational diabetes, like they had properly serious diabetes. And so there was more logic in arguing for induction of labour than we see with women now who, you know, had one high fasting test of 5.11 and then had absolutely no abnormal test results on their home blood glucose monitoring and have an, you know, apparently normal sized fetus. Who are then seeing recommendations to be induced in the absence of evidence that it improves outcomes.
Mel:
[27:03] Correct. So I'm bothered by that. When you were in practice and, you know, back in the day, back in the day, you know, in the olden days when you first started, you know, the research and a lot of the policies used to be around pre-labour rupture of membranes, you could wait for three days or so before recommending anything. Now they're doing them on the day of, you know, often within 18 to 24 hours.
Kirsten:
[27:31] Or during office hours the following day. You know, if you rubbed your membranes on Thursday, it doesn't matter whether it was 2 o'clock in the morning or 12 o'clock at night, then you'll be induced at 6 or 8 a.m. the following day. So, you know, which is clearly not about a logical scientific approach to the size of the risk. It's about managing workflows for institutions in a way that makes sense for them in terms of effective staffing.
Mel:
[28:02] Logistically, if a woman rings and says, hey, my waters are broken, and then the hospital says, well, come on in, because our policy is that we owe you an assessment, basically. We would like to offer you an assessment if your waters are broken. I've often seen it done that the woman's there. She's not laboring. There's no signs of labor. Her waters are broken. And they said, well, we could just induce you. You're not currently laboring. Whereas 95% of women will go into labor in the next few days and have their baby without an induction. But there's a logistical process of do we send this woman home or, yeah, do we help her have her baby in our business hours instead of waiting? So that's my next beef with these stats. 10%, that's a lot. It's a lot of women being induced for pre-labor ruptured membranes. And then the next classification of prolonged pregnancy, often there's a policy to induce women at 40 weeks and 10 days.
Kirsten:
[29:02] The way we're going, given that the gestational age is sneaking downwards, they're going to move that definition. This is Kirsten's prediction for 2030. And prolonged pregnancy will become 39 weeks and six days or something before we see it too far. You know, the whole, you know, 39 weeks now being considered as the optimal time to give birth in the absence of real evidence that that's true is going to, I think it's going to shift our definition of what's considered too long and therefore an indication for induction. You know, that going 42 weeks option, it will be increasingly rare.
Mel:
[29:45] Yeah, I have to agree with you. And I've even heard of some hospitals who are setting inductions at like 40 in three or 40 in six, and also more so just so they can fit everybody into the diary.
Kirsten:
[29:58] I think there's a really strong risk that care providers can get inside women's heads and quietly start undermining their self-confidence about waiting for labour onset from about 36 weeks onwards. And, you know, and we see that with, you know, why don't you try dates? You know, why don't you try red raspberry leaf tea? It'll bring you labour on sooner. Why don't you try evening primrose oil? why don't you try this physical movement technique or this acupuncture technique or this chiropractic technique or why don't we do a strip and stretch? It's all geared towards this idea that women lack the inherent capacity for labour to begin spontaneously and that women need to do a thing.
Mel:
[30:44] It feels like we've lost faith in physiology and that a lot of these decisions are policy-based, poorly based on evidence because, I mean, I've looked at the research on ruptured membranes before labour starts and it doesn't support an early induction policy. The whole thing with gestational diabetes being fraught and we don't truly know the full impact on society of bringing the babies out early before the woman goes into labour on her own. I just think we're really meddling with things and the stats show, you know, the main reasons for all these inductions. So, I mean, I think that's sad news. I'm having a drink.
Kirsten:
[31:28] Yeah, I'm having one too.
Mel:
[31:30] And when we start messing with that, knowing what that's going to do, I think it feels quite experimental to me.
Kirsten:
[31:38] And the unique communication that's happening between the fetus and the mother to say, yeah, yeah, I'm ready now. Yeah, we're not respecting any of that.
Mel:
[31:50] So 33% of women were induced, which means they weren't already in labour before they were given oxytocin or they had their waters broken or there was other means to induce them. But once labor starts so even if you happen to go into spontaneous labor there's still an option to be what we call augmented which means that if your labor is deemed to be not going fast enough they'll give you syntocin or artificial oxytocin if you're in America it's called pitocin but 15% of mothers will be augmented and that's 20% of mothers with spontaneous onset of labor. It's not a small amount. It says the augmentation rate was higher in first-time mothers. 38% of women who managed to go into spontaneous labor and not be induced and not have a cesarean section before labor had their labor augmented with artificial oxytocin, as did 19% of mothers who'd previously given birth. So it's not a small amount. Oh, I want to talk about breech positioning.
Kirsten:
[32:58] Yeah, let's do breech.
Mel:
[33:00] Let's do breech. That's not controversial. In 2022,
Mel:
[33:06] 4.2% of babies were in a breech position at the time of birth and 96% of those were given cesarean sections. That represents almost one in 20 pregnancies with a baby being breech. And my big issue with this stat, one in 20, when women walk into a hospital,
Mel:
[33:33] One in 20 of them are highly unlikely to be presented with a care provider who has the skills to serve their needs. And what I mean by that is that most care providers here in Australia, there are a few amazing heroes who are doing vaginal breech births. Some of those will be planned. Sometimes women just walk in and have a breech baby that was unexpected or they're pregnant with a breech baby and nobody realized and then they had their baby and everyone went, whoa, that was breech. But that's 4% of breech babies are being born vaginally and that's not because women don't know how to have breech babies or that it's necessarily more dangerous than having a baby, a breech baby by cesarean section. It's because clinicians don't know how to do it. And so women are being told that their only option is to have a cesarean section. And that means we as a maternity care system do not have the skills, we've de-skilled ourselves to care for one in 20 women.
Kirsten:
[34:37] Do you know what else affects about one in 20 women?
Mel:
[34:40] What's that?
Kirsten:
[34:42] Preeclampsia. Do you know any obstetricians that would go, oh, I'm sorry, I don't do preeclampsia, you'll have to go to another hospital?
Mel:
[34:50] Right, 100%. I know. And it's almost like, too, I think about this with shoulder dystocia, right? We are drilled as, like, clinicians to get shoulder dystocia management into the deepest part of our brains so that when it happens, our subconscious reminds us how to get a stuck baby out, right? We're not doing that.
Kirsten:
[35:14] You don't go into panic. You just go step one, step two, step 25, let's keep going, until you solve the problem. And instead we don't even get to step one with vaginal breech birth because it's like, oh, that's terrifying and I don't know what to do. And, you know, choosing, it's a choice to not know what to do with vaginal breech birth. If you're providing care for women who give birth, it is an active choice to not go and develop those skill sets. As I said, you know, people choose to actively go and develop skills about how to manage a woman who's got preeclampsia, how to manage a shoulder dystocia, how to manage postpartum hemorrhage. We have this big weird blind spot when it comes to vaginal breach that says oh no it's just too hard so it won't.
Mel:
[36:11] Yeah and it's not even i don't understand it no it's not even like pathology it's not even like it's a big serious illness where people go oh that's a bit complex it's actually very straightforward to be able to recognize when a breech baby's not coming in the position it should. And then there's a handful of strategies that you can apply to unstuck a stuck breached baby, and most of them don't get stuck. The stats on that are about 30% of breached babies will need some kind of hands-on assistance to be born. And that's not usually a majorly complex assistance. It might be a simple maneuver. And so a skilled clinician can manage that 30% of breech births that need some assistance.
Kirsten:
[36:58] And most of the manipulations are the same that we learn as obstetricians in order to be able to achieve the safe birth of a breech baby who's born by caesarean section. You still have to get them out of a small space inside a uterus and manoeuvre them and manipulate them in order to be able to achieve a birth that doesn't cause injury to the baby, they are fundamentally the same skills. And I think it's one of the great mistruths of our time that obstetricians don't have the skills. They may not know that they have the skills, but if they're doing breech caesarean sections, then they already have many of the skills required.
Mel:
[37:46] Honestly, I've done an online breech course and two live ones. It's not that complicated. And in fact, midwives are taking back this skill set in the absence of a huge collection of skilled obstetricians, midwives are taking back the skill set and rightly so. It's just physiological birth with a baby the other way around. You know, we had Dr. Stu Fishbane out here not long ago and at least 100 midwives did his breech training. Breach Without Borders is coming back to Australia through March, April and May next year. So people have an opportunity to take these skills up. There's online training courses. But also, even if you're not intending as a clinician to be caring for women who have a known breech baby.
Kirsten:
[38:35] Yeah, maybe you work in a health service where it's considered outside of the scope of that health service. But yeah, there will be still, women don't get a choice. They don't have a choice about having a vaginal breech birth. But as care providers, we have a choice about whether we will have the skill set or not to be able to care for that woman safely. It's a great travesty that it's become acceptable for obstetricians particularly, but even for midwives to go, oh, no, I don't do that.
Mel:
[39:04] Well, and the other issue is, is even if your health service doesn't do it and you don't want to actively pursue, you know, or you don't want women to actively pursue you as a breech practitioner, you may and probably will be presented with a surprise breech baby at some point in your career. And I think it's negligent to be working in birth work and not know how to even firstly identify that a breech baby is stuck because this is one of the issues is if you're an untrained clinician, you don't even know what a normal breech birth looks like, which means you don't know when is the right time to put your birth. Yeah, because if you think, yep, baby's coming, that's great, no problems, but a trained clinician might look at the position of that baby and say, that baby's not going to come. I can see that in the next three to four minutes, we're going to have an issue simply because of the way that baby's belly is facing. I just think it's a complete travesty and a tragedy that one in 20 women cannot have their needs met because us as a profession have chosen to de-skill. So I'm drinking to that because it's sad. But also it's good that there are opportunities to upskill and that everybody can.
Kirsten:
[40:28] Yeah.
Mel:
[40:29] Oh, that's so good. That's a good drink. Let's have a look. So that's breech. Oh, wait. Did we talk about the stats of cesarean? I don't know if we did.
Kirsten:
[40:41] We talked about pre-labour cesarean section. We haven't talked about cesarean sections in labour. And we haven't talked about the reasons that people are doing cesarean sections these days.
Mel:
[40:51] Okay. So let's look at that. So there has been an increase in cesarean section births by at least 1% in 2004.
Kirsten:
[41:01] And that may not sound like much, but if it's 1% a year across a 10-year period, that's a 10% increase and I'm having a drink.
Mel:
[41:13] Let's have a drink. It is a 10% increase. Also, it's been consistently increasing by about 1% a year. So the rate of caesarean section, well, 2010, it was 32%. 2012, it's 39%. 39% of women are having their babies by cesarean section.
Kirsten:
[41:38] That's two in five. Yeah.
Mel:
[41:40] Yeah. So that's almost two in five women and it's an increase. So that includes those who had no labour onset, that's 65%, and then 35% of those numbers had a cesarean section after labour started. 52% of preterm babies were born by cesarean section. If you are aged 40 or over, 57% of those women had caesarean sections, and women who were considered overweight or obese, 47%. I don't think that's a good idea to be favouring caesarean section for women who have higher body mass.
Kirsten:
[42:21] Who are more likely to develop complications around the time of surgery with increased risk of wound infections, chest infections, blood clots.
Mel:
[42:31] Right. So it doesn't make a lot of sense. And I mean, if you're bigger, it doesn't mean that you're less capable of having a vaginal birth unless there's a particular perspective of your care provider where you've been given less opportunity for that. So that's a bit, that's disappointing. Not only that, but internationally when we compare Australia to other OECD countries, Organisation for Economic Cooperation and Development countries, this is often who we compare ourselves to, OECD countries, the Australian rate of caesareans was higher than the OECD average. So the average in comparable countries to us is 28 babies per 100 live births. Australia's rate of caesarean section is 34 per 100 lives births. Not only that if we break it up If you're having your first baby, the chances of you having a cesarean section is not 39%, it's actually 41%. And if you've had a baby before, it's 13%. So this differs if you're having your first baby and you're going into hospital.
Mel:
[43:43] Firstly, your chance of induction is higher and so too is your chance of cesarean section. So it's rough for first-time mums. very few comparatively get to go into spontaneous labour, aren't augmented, and have a vaginal birth without an episiotomy or vacuum or forceps. These are becoming the more rarer circumstances, which is really the whole reason for the Great Birth Rebellion podcast, to be honest, because of these statistics, particularly for first-time mothers.
Kirsten:
[44:14] And you and I both know that there are many, many women out there who line up for baby number two saying, I went into my first birth trusting that the maternity care system would look after me, that they would provide me with the right advice for my situation that would support me to have a really good, safe birth experience. And then they turn up at the start of pregnancy number two going, I was so let down last time. I need to go and educate myself because I can't trust that the system's going to do that for me.
Mel:
[44:52] You know, this represents, I think, an inappropriate level of intervention. And I'm saying that partially by the amount of research that's banked in my brain, you know, historically, but also, you know, I'm a home birth midwife with a hospital transfer rate of around 10% on average, which means that 90% of my clients give birth at home without vaginal exams, without inductions, without augmentations, without vacuum, forceps, cesareans. And these are not a collection of low-risk women either. I'm at a point in my career where I'm capable of caring for women who have risk factors like diabetes and who have had cesarean sections previously and all kinds of complications that would otherwise put women in line for numerous amounts of intervention. I've witnessed the capability of at least 90% of my clientele who can give birth with relative few complications or needing relatively few interventions. And so it seems ludicrous to me that 41% of women in Australia are given cesarean sections because I cannot believe that it's necessary.
Kirsten:
[46:08] It's not that women's bodies stopped knowing how to give birth.
Mel:
[46:12] No, no. There's been a fundamental change in how we're delivering services and that's what's infuriating. And some women will be listening and some care providers will be listening saying, yeah, but some women need cesarean sections. Absolutely, we are not disputing that. And the World Health Organization will tell you that around the 15% mark is the sweet spot for where you're going to actually experience benefit from this kind of intervention but
Kirsten:
[46:39] Once you start... Anything above 19% is typically associated with worse outcomes.
Mel:
[46:46] Which actually is what we're seeing, right, with pushing risk uphill for the next babies. So for women who want to try and have a vaginal birth next time, around 79%, I'll have to have a good look at those stats. Hang on. So what's happening then is when women have this first cesarean section, 41% of first-time mums who are having their first cesarean section, most of them will go on to have a repeat cesarean section. So 76% of women who had a previous cesarean section will end up with another cesarean section if they give birth in a hospital. That's certainly not the stats if you choose to have your own continuity of care provider. There are a lot of obstetricians supporting VBACs and private midwives definitely are supporting VBACs. And so those stats are almost flipped by the way. So if you've had a previous cesarean section and you go to hospital to have your baby, 76% chance that you'll have a repeat cesarean section. Whereas if you have your baby at home, those stats are almost completely flipped. There's like between a 75 and 85% chance that you'll have your baby through your vagina. So the main reason for cesarean section is that you've had a previous cesarean section. That's the number one cause.
Mel:
[48:11] Because she had a cesarean last time, we're going to give her one this time. Which is so scandalous considering that the research on VBAC, all of it, even if you've had two or three cesarean sections, is supportive of at least supporting women to try and have a vaginal birth. That's the advice. There's very few research papers that say we recommend that women have a repeat cesarean section. The majority of them say all women should be offered the opportunity to have a vaginal birth even if they have had multiple cesarean sections and certainly the stats on that so it says mothers who have previously given birth and had a cesarean section no I don't know what that sentence means I know hang on maybe the drink is kicking in okay I have a sentence here it says of mothers who have previously given birth and had a cesarean section So the 39%.
Kirsten:
[49:07] Yeah.
Mel:
[49:09] 25% had a previous cesarean section. Okay. I think that makes sense.
Kirsten:
[49:15] So they've had at least two cesars before.
Mel:
[49:18] Of mothers? Okay. We're definitely, okay. Of mothers who have previously given birth and had a cesarean section, 25% had one previous cesarean section. Oh, 5.8% had two previous cesarean sections and 1.5% had three or more. And this is with reference to VBAC. Oh, no, I don't even know what that sentence is trying to tell me.
Kirsten:
[49:47] I think you're saying that when women are attempting VBAC in the current system, the chances of them attempting a VBAC after two or three cesarean sections is pretty slim.
Mel:
[49:58] We are a little bit.
Kirsten:
[50:01] Let's drink to our confusion.
Mel:
[50:03] To that. Okay. I read it word for word. For those of you out here who aren't partway through a cocktail, that may make sense to you. Okay. All right.
Kirsten:
[50:17] Look, I'm a big fan of women making their own decisions, and I think if you've had a pretty awful birth experience the first time around that resulted in a cesarean section, there are some women who go, you know what, I'm not doing that again. I'll have a caesar. Thank you very much. Valid choice. And as long as somebody actually gives you some fairly accurate information about the pros and cons of that, and you weigh it up and make that decision, good on you. I'm not saying that all women who've had a previous cesarean section should attempt a vaginal birth because you know not everyone wants to but i i often see women being told they're not allowed we don't do them here you're not a good candidate um or the whole bait and switch thing that you know at booking yeah yeah great good idea then they get to 36 weeks and it's oh the baby's a bit big and it's not in the right position and you know or you've gained a bit too much weight or whatever that's just designed to undermine people's self-confidence or look you probably really need to be induced but we don't do inductions for women having a v-back so let's just book you in for a cesarean section so you know there's some fairly widespread nonsense that goes on for women who are intending to have vaginal birth after cesarean section and that's before we even get into a very long conversation about what happens around CTG monitoring for that.
Mel:
[51:45] Well, and the other issue is even if they do get to the point where they go into spontaneous labour in a facility or with a care provider who supports their opportunity to VBAC, the policies around the care of women who are having a VBAC are really restrictive. So like you said, the continuous CTG, often they are held to kind of more strict timeframes for how long their body can labour for before they'll be recommended a caesarean.
Kirsten:
[52:19] Some places will restrict women's access to water immersion.
Mel:
[52:22] Yeah, all these things that, you know, they just, there's so many barriers. So I understand this statistic because you and I know all the barriers that women have to jump through if they do want to have a vaginal birth after cesarean section. And even if they get to the point where they're actually in labour, you know, the gauntlet's not over, absolutely women can choose to have a repeat cesarean section. But I think that the main driver of this is that they're not given the opportunity to have a vaginal birth in a supported facility. So I'm going to have another drink because that's disappointing, especially when we know and the research shows that your chances of having a vaginal birth after caesarean at home are the opposite. You know, you'll have a 75% to 85% chance of a vaginal birth. So it's not like they can't do it. Sometimes just hospitals won't.
Kirsten:
[53:17] You keep talking. I need to refill my glass. Yeah.
Mel:
[53:20] Oh, whoa, hardcore. I'm just still halfway through, but please do fill up your glass. We're drowning our sorrows. That's the purpose of this. Yeah. Keep talking. Yeah, I'm watching Cursor make a cocktail. Okay, I'm going to keep talking. I'm not going to talk about maternal age because we're planning to get a bit long in the stats.
Kirsten:
[53:42] One thing I would like to say about maternal age is that, yes, Yes, the average age of women has increased ever so slightly, but the good news, and we don't need to have a drink for, is that one of the reasons why that's happened is that there's been a progressive reduction in the number of women giving birth under the age of 20. And while there may be a handful of women who are aged less than 20 who actively choose to become a parent, many of those pregnancies are the, oh, that wasn't quite part of my life plan.
Mel:
[54:19] So you're thinking women are making more conscious choices around their pregnancies because of,
Kirsten:
[54:27] Yeah. Back in my day, you know, we had the pill and it had a 15% annual failure rate, whereas the modern contraceptives, it's less than 1% unintended pregnancy rates. So we're not seeing the 16, 17, 18-year-olds who are having to explain, oh no, mum, I'm having a baby in the same rates that we used to.
Mel:
[54:53] You know, when people talk about women who are older having babies, they make it sound like, you know, half the population is having their baby over the age of 45 and they're all perimenopausal. And so now that's why the intervention rate is increasing because women are getting older and fatter and sicker. But actually, in 2010, for women who gave birth, we're 30. And now in 2022, it's 31.2. It's not really that much. The age of first-time mothers has increased similarly. And as you said, the proportion of women who are giving birth under the age of 25 has decreased from 18% to 11%. So it's possible that everyone's just having babies when they plan it. So birth location, and I want everybody to take this with a grain of salt because these stats, birth location, have changed very little from like 10 years ago. So still about 90% of women give birth in hospitals. 75% of those will do so in public hospitals.
Mel:
[56:02] There has, however, been a year-on-year increase in the number of women who are having home births. So it's gone up in 2019, 0.3% of women, which totals to 923, gave birth at home. In 2022, 1,787 babies or 0.6% were registered to have given birth at home in a home birth planned with a private midwife. Some caution around this because that's a tiny number and I know almost for certain that there are way more than 1,700 babies being born at home with private midwives.
Mel:
[56:48] The big issue is, is that midwives are very poor at data entry and they don't always send their perinatal data collection forms in. And that's how they calculate the number of babies who are born at home is through the perinatal reporting system. And I've got colleagues, you know, like midwives within, you know, 100 kilometer driving distance from me who I know have piles and piles of perinatal forms waiting to be put in and that haven't been put in. So I'm going to hazard a guess.
Kirsten:
[57:23] Midwives, get to it. We need good stats. So the bell and I have to drink so much next year.
Mel:
[57:30] Exactly. I'm driven to drink because, and I keep saying to midwives, I'm that midwife sending out messages on every single group chat that I can find that it contains private midwives to say, please put your paperwork in so that home birth can be properly recorded because government doesn't want to service the needs of 1,700 women when they're writing policy,
Kirsten:
[57:55] Right? If it's seen as a fringe niche thing that a very small number of the population are interested in, there's no need to introduce insurance, for example, or Medicare provider numbers or item numbers to support it.
Mel:
[58:12] I know, and put in place pathways and strategies to enhance the private practice midwifery workforce or, yeah, fund it.
Kirsten:
[58:19] And it's easy to dismiss the safety of it by saying, oh, but the numbers are small.
Mel:
[58:25] Exactly. Like, not many are doing it. So it's not that big a deal. Actually, way more people are doing it. And I know that because I know lots of private midwives and I, you know, have a vague understanding of their caseload. I want to say that. It's definitely not. That's an incorrect stat. mostly because I know that midwives don't put their paperwork in. The other thing that's increasing is there's a small, so when I did my PhD, which was on birth outside the system, one of the issues is that it's very hard to know how many women choose to give birth at home in a free birth circumstance, for example, without a midwife there, because the stats of that are mixed up with their stats on what we call born before arrival. So where the woman is intending to go to hospital or whatever, doesn't make it for whatever reason because her labor goes quickly and she ends up having the baby outside of hospital. So the stats on babies who are born before arrival or intended to be born at home without a care provider sit actually higher than And the home birth rate, so it's 0.9% in 2022 gave birth either born before arrival or an intended free birth compared to 0.6% of women who home birthed. So already I've told you that.
Kirsten:
[59:50] That's probably underreported because those women don't necessarily fill out perinatal data collection forms either.
Mel:
[59:58] Yes, some of them don't register their babies either. So there are babies out there that are existing off the grid. But what we are seeing is a definite increase in that particular stat of sort of unclassified births, births born before arrival, and that's where the free birth stats sit. So anecdotally on the ground as midwives, private midwives, we've noticed an increase in women accessing home birth that was quite poignant through COVID and also with various changes that have occurred in legislation and things like that. So anecdotally, home birth midwives have noticed an increase in home birth. Also, on the ground, sort of in a culture, if you've got your finger on the pulse of the free birth culture, a lot of people are noticing an increase in women who are choosing free birth. So in terms of location, that's where we're up to, but still the vast, vast, vast majority, 97% are giving birth in hospital.
Mel:
[1:00:57] That's what I had to say about birth location. And most of those are in public hospitals. there'd be around 20% who are giving birth in private hospitals. The other thing that really is not that great but continuity of carer so you know we bang on on this podcast all the time about the importance of one-to-one care provided by the same named care provider across the full continuum of maternity care and some women choose to do that with their known obstetricians some people choose to do that with a known midwife. But over a third of models in maternity care have no continuity of care option and 36% of women have no continuity of care at all at any stage of their maternity care period. About 35% have continuity of care for some part of their period. So 19% will have the same known midwife through their antenatal care, pregnancy care.
Mel:
[1:01:57] 14% know the same midwife through their antenatal and postpartum care. And around 29% of women are in models of continuity care through their whole maternity care period, where they have a single named care provider. It's higher in some states. But continuity of care or continuity of carer is considered the gold standard superior model which has the best outcomes both physically but also in terms of satisfaction and emotional satisfaction and health for women is continuity of carer whether or not it's a midwife or an obstetrician that's the best outcomes yet only 29% of women have access to that in Australia.
Kirsten:
[1:02:42] A good part of that is that we now are collecting those statistics. And, you know, even three or four years ago, I know as a researcher, if you wanted to find out the number of women in Australia having continuity of carer, there was just no number you could go to because no one was counting it. So at least it's now being counted and it will become something that counts in terms of government departments. We need to start seeing 98% of women having continuity of carer relationships, and then we'll see some of the much desired improvements in maternity outcomes that come along with that, that we aren't seeing in standard models of care.
Mel:
[1:03:23] Absolutely, and that was going to be my next point. If we just did one single thing of allowing women to choose their care provider that they'll have through their whole pregnancy, then I think we could, by next year, the mothers and babies report would look so different just because we did a tweak to the model of care.
Kirsten:
[1:03:47] And did it be no-y-but to the healthcare system.
Mel:
[1:03:51] And women would be more satisfied. They've told us that. We know a lot from research about what can change when you give women a choice of their care provider and they have the same care provider through their whole pregnancy. There's been really solid research about what that can do. And we could certainly change this whole thing around. We wouldn't make small increments of improvements, what I'm trying to say. We would make, it would look like a completely different collection of statistics. And what that tells you is that the maternity care system has the power to impact women's birth outcomes and so there are women out there blaming themselves for certain outcomes and certain things that happen to them in their birth but you've got to know that there's so much power in how services are provided in terms of what your outcomes are going to be. So much so that the minute we change it, we see huge changes in outcome. We're going to move on to the next things because otherwise we'll be here forever.
Kirsten:
[1:04:49] I'm keen to get to baby outcomes because, you know, surely all these extra cesarean sections and all these extra inductions, you know, we're doing them because there's some belief that that's going to mean that, you know, we have fewer poor outcomes for babies. So, you know, we must be seeing some improvements there Mel.
Mel:
[1:05:11] Well that's really that's what the healthcare system would say is all we're trying to do is keep women and babies alive and in good condition that's why we're doing this it's all for your benefit so that everyone is kept safe. So you'd be really wanting to see with this increase in cesarean section and actually also the episiotomy rate's pretty shit, like it's like 25% or something like that. With all of this intervention, I think we could all tolerate it a bit more. Women and care providers, we could tolerate it a bit more if we were seeing significant changes in the health and well-being of babies and mothers. Let's look at the mamas first, right? The amount of times women are told you could die or that your baby could die is significantly disproportionate to the number who actually do die. So in 2022, very sadly, there were 14 maternal deaths of the approximate 295,000 women who had their babies this year. 14 died. Maternal deaths, though, is any death that occurs for a woman who's pregnant through her birth and 42 days after she's had a baby. It's not like just a woman who dies in childbirth. Maternal deaths are any time in pregnancy, birth, and 42 days after.
Kirsten:
[1:06:39] And it includes women who die in car accidents, women who are killed by their partners, women who die in a workplace accident. it's not necessarily a complication that arises as a consequence of being pregnant.
Mel:
[1:06:55] The other reasons why women died, so only the leading causes of maternal deaths in 2022 and prior were actually non-obstetric reasons. So cardiovascular disease is trending as the most likely reason that women will die in pregnancy. Non-obstetric hemorrhage, so bleeding from some kind of trauma or disease process so not related to their pregnancy. Sepsis is the next cause and suicide. Women hurting themselves and pre-existing conditions and infections such as sepsis are the main reasons why a woman would die and the majority of the reasons were not what they call obstetric reasons so not linked to the woman's actual pregnancy. So that represents a rate of 4.8 deaths per 100,000 women. This is a very different stat for our First Nations women though. The maternal mortality ratio for First Nations mothers is about four times higher, 16.9 per 100,000. The reasons for that are inexcusable.
Kirsten:
[1:08:06] It's not that they're weak and inferior and make bad choices. No, no.
Mel:
[1:08:15] No, it's that service provision is unsuitable for First Nations women.
Kirsten:
[1:08:20] There might be no service provision.
Mel:
[1:08:22] Correct. Yeah, the care that's offered to them is usually culturally unsafe, you know, and there's just a fundamental racism embedded into the healthcare system. Yes, so there's still an incredible inequity between white Australians and our First Nations sisters. So, yeah, it's too large. There's no excuse for it except that we're just really poor at servicing the needs of First Nations women.
Kirsten:
[1:08:49] Yeah, that needs a drink because it's not good enough.
Mel:
[1:08:52] That does need a drink. I forgot about my drink. It's yes.
Kirsten:
[1:08:56] That's what happens when you start drinking.
Mel:
[1:08:59] Oh, I forgot I'm supposed to be drinking.
Kirsten:
[1:09:01] What are we doing again?
Mel:
[1:09:02] What are we doing? Oh, that's right, babies. Okay, so your question was, has all this intervention made it better for babies? Basically, there's been very little change in the statistics for stillbirth, perinatal death or neonatal death statistics since 2002. And in some categories,
Kirsten:
[1:09:23] Actually... 2002, so 20 years and we have an improved thing. Yeah.
Mel:
[1:09:27] Yes.
Kirsten:
[1:09:28] Reaching for drink.
Mel:
[1:09:31] Reaching for a drink. We haven't changed it really. It fluctuates between like 1.2 and 1.5 in the rate and it's very little changed. No, we have pretty much not been able to affect stillbirth, perinatal death or neonatal death statistics. They've been very, very stable.
Kirsten:
[1:09:50] Despite all these increases in cesarean section and all of the increases in induction of labour and the stagnant change, stagnant rates of instrumental birth and the increased labour augmentation. We're not making outcomes for babies better, but we're making outcomes for women worse.
Mel:
[1:10:12] The thing that is going up, okay, so in 2010, 15.9% of babies were admitted to special care nursery or NICU. Now 16.9% are being admitted to special care or NICU. So we're actually, with the increase in interventions, we're not decreasing deaths of babies, but we are increasing admissions to NICU.
Kirsten:
[1:10:40] Which fits with the idea that gestational ages are coming down, because even at 39 weeks, if you induce labour or do a cesarean section, some of those babies really aren't ready and are more likely to end up in special care with needing respiratory support, temperature support or feeding support than had you waited another whatever it was for that baby a week or two or three for them to go, hey, I'm ready. Let me hit the exit button. At least part of the explanation for the rise in admissions to the nursery relates to, Prematurity is not quite the white word because a lot of these babies are still at term, but babies that are not quite ready for life outside of the uterus.
Mel:
[1:11:29] Well, this is the thing is there's a reduction in the age of babies being induced and already induction is an additional stress on babies that they weren't anticipating in their lives. They're not made for that level of stress. They're made for physiological labor. Elective cesarean section also poses an increased risk that babies are going to not transition adequately to extra uterine life and might need a bit of extra assistance. But yes, the early preterm babies who are being induced early.
Kirsten:
[1:11:58] Oxytocin increases the risk of developing disorders related to lack of oxygen supply, hypoxic ischemic encephalopathy, for example.
Mel:
[1:12:07] Yes. So look, there's way more stats and we definitely didn't do justice to the discrepancy between general stats and the gap that's experienced for First Nations mothers and babies. There's been some improvement in that in terms of access to healthcare, but it's not significant. So there's still a huge public health issue there with making health services appropriate and accessible to First Nations women. Generally, the intervention rate is going up. Overall, there's some small improvements. I just, yeah, I don't know what my closing statement is here. I'm just in some disbelief that we haven't managed to curb what's going on with the over-medicalising.
Kirsten:
[1:12:51] Well, let's talk about solutions. What do we know that works? Well, we know that having a known care provider, and particularly when that care provider is a midwife, reduces intervention rates. It reduces the expense of health service provision and it increases women's satisfaction with the service that's been provided. And there's increasing evidence that is also great for midwives. There are lower burnout rates for midwives who are working in continuity relationships with women rather than standard shift-based models. So, you know, a strong commitment from midwives and from health services to provide continuity of carer for women. And women tromper through the front door of the hospital and going, no, no, you're giving me a spot in the MGP. And if you're not prepared to do that, then I'll have my lawyer write to you and you'll have to explain why you're providing me with inferior care.
Mel:
[1:13:49] There's
Kirsten:
[1:13:49] Potential for change there.
Mel:
[1:13:50] And you know when you say you know it's it's cheaper to provide midwifery continuity of care for the hospitals yes it's it improves outcomes and in fact it doesn't make outcomes worse even for women who have risk factors so we know that actually all women having access to midwifery care is at the very least not going to make stats any worse because But we know it actually makes things better financially for service providers, experience wise for women, outcomes wise. So yes, number one solution would be to prioritize services that allow women to choose their care provider. And that includes political and legislative and financial support for the work of private practice midwives so that women can have home births. So the next step is to firstly open women up to the option of a midwife as their lead care provider and then open up the menu for, okay, well, now where do you want to have your baby?
Kirsten:
[1:14:53] Yeah, so an expansion of publicly funded home birth models or even, you know, birth centre style care. A lot of that's moved off the political agenda. Oh, you're in the MGP, that's good enough, but you still give birth in the standard birth suite in a setting where there's often central fetal monitoring, so there's no privacy and you're under obstetric surveillance the entire time. I think we've lost sight of the value of having private bases for women staffed by midwives that are not part of the main obstetric services within hospital organisations because the other thing that needs to happen is increased resourcing of services for Aboriginal women and there are some fabulous models and where they exist they work really well. So Waminda in Nowra in New South Wales, Wajumpajarjams on the Gold Coast, the BIOC models in Brisbane, you've probably got ones that are you know about that are Sydney-based, particularly when their services are provided by Aboriginal health workers and Aboriginal midwives, then they're starting to see significantly higher levels of engagement with health care, higher satisfaction rates and better outcomes across the board.
Mel:
[1:16:10] One of the other rising issues that I'm seeing is that hospitals are trying to satisfy this requirement. I mean, I think there is a push to start to have continuity models. They're starting to dilute them with services that provide continuity, for example, for eternatal, postnatal. But when you turn up for your birth, you still are not with your known midwife. I can't remember the name of the services, but they have a particular name. Maps.
Kirsten:
[1:16:37] MAPS. Midwifery, antenatal and postnatal service.
Mel:
[1:16:43] Right. And my understanding is they're allowed to bundle that into their continuity of care tick box. And so actually some hospitals can say, yeah, we've got a continuity of care model, but it's actually MAPS and it doesn't include birth. So it's not continuity across the full scope. So, I mean, just some caution around that. So yes, solutions are continuity of care.
Kirsten:
[1:17:07] It's one of those, it's better than nothing, but it should be a stepping stone along the pathway, not a final destination.
Mel:
[1:17:13] Yeah. Rather than people going, yeah, we did it. And they're not intending on going the full way.
Kirsten:
[1:17:19] And I know there'll be a lot of midwives out there going, oh, but you don't understand. I can't work in a continuity of care model. The on-call components do challenging for me. And I acknowledge, having been somebody who was in private practice obstetrics and who was on call 24-7, you know, at periods in my life I was doing 12 days out of every 14 on call repeatedly, like over the course of a two-year time period.
Kirsten:
[1:17:45] It is demanding. But a lot of the reason that it's demanding is that we live in a society that doesn't value women as mothers and that mothering work is, you know, parenting work is pushed onto us as mothers. It's not shared equally across partners in relationships and there's little, support women are meant to, you know, the whole it takes a village stuff goes out the window and women are meant to individually manage parenting all on their own without support. And we need some, you know, for midwives to be able to engage in these models during their years of early parenting, we need much better support for them. Adequate levels of funding so that they can afford appropriate childcare that meets their needs so that they can actually provide services. And a whole lot more flexibility in healthcare services. You know, I remember taking a small breastfed child of mine to work once when I got called out unexpectedly and childcare arrangements had fallen through. And whilst the midwives who were on the shift thought it was a hoot and loved playing with the child, I got called into the office for a big please explain the next day. And I think, you know, we need to be a whole lot more forgiving about that kind of stuff and recognise that services just need to support women being able to turn up and provide care in the best way that they can on the day.
Mel:
[1:19:14] There's also a lot of midwives in that position and they are happy to be an MDP midwife if, for example, they could have a job share scenario or they could be in a team situation or there was that flexibility and the supportive workplace.
Kirsten:
[1:19:31] Yeah, they could halve the number of hours that they were on call each week and share it with somebody else.
Mel:
[1:19:36] And also, over time, if our midwifery training and midwifery system changed, then midwives would enter into midwifery with the understanding that this is how we provide care is continuity. I know the New Zealand midwives enter into their career knowing that that's how they're going to be working and that's the expectation. So over time, I think people will enter the workforce, the midwifery workforce, expecting that. But at the moment, they don't have to.
Kirsten:
[1:20:06] And as you said so nicely in a previous podcast past, you know, we start where we are and with what we have. And if you genuinely are not in a position where it's just, you know, it's simply unrealistic and not doable for you, go and find a midwife who either is doing it or has the potential to be able to do it and be their support system for them so they can provide continuity of care. Be the person that they can drop their babies off to, be the person who does the grocery run for them or goes and retrieves their clothes off the clothesline when the rain's coming over because they're still at work looking after somebody that took longer than expected. You know, the simple little acts that we as women can do and others to support midwives, to be able to support birthing women so that they can have the care that they deserve. It really is a social model of care midwifery, it's much more than just being a professional and it's about us all looking after each other so that, you know, the care providers can then provide care.
Mel:
[1:21:09] All right. There's like a million other things we could talk about in this episode, but I realised that we are two drinks deep. And we haven't even covered half of it, but I think it gives people a vague idea of what's going on here in Australia. It presents to women what they might be up against. If you are seeking a low intervention birth under the care of midwives, then just know that the flow currently in the Australian maternity healthcare system is geared towards you having a birth that is not that. And so you just need to be prepared for what might occur and you know make certain strategic choices along the way there's whole episodes dedicated to how to have physiological births in hospital and you know how to navigate the maternity care system but just know that the current flow for women who want to go with the flow the current flow is medical the current flow is high intervention they will say that this is because we're trying to keep you safe but actually there's been very little shift in the hard numbers of how many women and babies are being kept safer. And in fact, if you want to look at the very raw stats of the number of babies who are going to need a natal intensive care unit, that's actually increasing. And now it's up to women and families and care providers to take this information on however you will. I don't think I should keep talking because this is now a tipsy rant.
Kirsten:
[1:22:38] An editing Mel might regret the work that she has to do. I'm feeling like I could have a nap now.
Mel:
[1:22:47] Oh, go. We should do that. We should nap. Thanks, everybody. That's been this week's episode of The Great Birth Rebellion. That has been the 2014 Women's and Babies Report, but they're the 2022 stats. And we'll see you next week.
Kirsten:
[1:23:05] I think you meant it was the 2024 one. but that's because we're two drinks in and we're lightweight. What did I say?
Mel:
[1:23:12] What did I say?
Kirsten:
[1:23:13] 2014.
Mel:
[1:23:16] Oh, no. Okay, it's 2024. If you want to actually see the full report, you can just Google Australian Women and Babies Report, 2024. It's 2024 but it was 2022 stats, not 2014. That's a wrap. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com. And to support the work of this podcast, wear The Rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
This transcript was produced by ai technology and may contain errors.
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