Episode 190 - When do I NEED an obstetrician?
[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.
[0:24] Hello and welcome to today's episode of the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson, and I'm a midwife and will always advocate for all women to have access to midwifery care. But today I'm going to discuss at which point would it become a medical necessity to also engage with an obstetrician for your care. But before I go into any of that, and we dive into any of the scenarios under which you might need an obstetrician. In order to keep this podcast completely free to you, the listener, I've welcomed a very few generous and carefully selected sponsors who make it possible for me to keep making this podcast for you. And this episode is sponsored by my dear friend and birth prep extraordinaire, Poppy Child from Pop That Mama. She's a doula and hypnobirthing practitioner, and her online hypnobirthing course called The Birth Box has already helped thousands of women get ready for labor. Listen to this recent review of The Birth Box. The woman says, I'm a first-time mom and I gave birth to my beautiful baby boy yesterday. I've been listening to the birth box on repeat for the past few months, including the day in which I went into labor. And I had the most empowering birth experience. And I can honestly say that listening to the birth box was a huge part of this success.
[1:51] Reframing the pain that you experience during labor can be a purposeful pain instead of a harmful pain. And that really helped me to know that. and just being able to surrender to the wild ride that birth is and let my body take over was the most incredible thing. And this is coming from a pelvic floor physiotherapist based here in Australia. She says, I will recommend it to all my patients. And you know me, I'm so picky about what I will endorse, but I do get behind the work that Poppy is doing. And in the birth box, you'll learn tools to help you manage pain and how to stay steady when labor gets intense. It's all about giving you knowledge, confidence, and a mindset that actually works when the big day comes and for the big days that will follow.
[2:41] Birthbox is rated five stars across the board. And with my code, Melanie, you'll get 25% off. So if you're preparing for birth, go to the checkout.
[2:52] You'll be so glad you did. The link is in the show notes. Use the code Melanie to get your 25% off. Okay, let's get started in today's episode, which is all about situations in which you would need an obstetrician to become involved in your care. And I know there are many women listening who have actively chosen to hire an obstetrician or chosen obstetric care despite being well and healthy. And of course, that is completely your choice and your decision. And I will never poo-poo a woman's considered decision to hire women. The care provider that they feel safest with. And I also want to say that obstetricians are tasked with high level complex care scenarios and are required to think on their feet, exhibit expert control over their emotions, stay calm under pressure, they have highly skilled hands, they navigate the most high risk and high stakes situations out of all the other maternity care providers.
[3:56] So being an obstetrician is commendable. I would definitely not want to do it. I'm a midwife and my job is to nurture women through a normal physiological process, through their pregnancy, birth and postpartum. And then when things get complicated, I know that I have a next protocol whose job it is to be the responsible care provider when things get complex.
[4:19] But imagine being the person who only gets called when things are not going right and everyone is expecting you to perform and not make mistakes and provide the emergency and rescue care that can sometimes occur that sometimes is needed during pregnancy birth and postpartum.
[4:38] Imagine knowing that you are responsible and there's no escalation button to push or to make the next call. You are it. You're the last person in line, you have to solve this problem. So this is the role of an obstetrician and I will never diminish society's need for these expert caregivers. This episode is not about diminishing the work of obstetricians. The truth is we know that when we need you, when we need an obstetrician, we need you. And when we don't need you because everything is going to be fine, we don't need you. So please, kindly.
[5:18] If you're an obstetrician, don't interrupt when you're not needed.
[5:21] And please, when you are needed, we would love you and welcome you into the care of women. So in this episode, I do want to speak to the women who have no specific medical need for an obstetrician, who have unconsciously chosen to hire one. But today's episode is about exploring how to best utilize the specialist skills of an obstetrician and how to know when they're not needed. So let's get into it. But before I do, in order to keep this podcast free to you, the listener.
[5:53] We have a very few carefully selected supporters who generously sponsor this podcast. And if you are a woman and family learning about care options, I want to introduce you to the birth time documentary. If you've been listening to this podcast for a while, you'll know how passionate I am about women having great births. And this documentary puts into a neat 90-minute package so much of what I've been trying to tell you over the last three and a half years. Before the Great Birth Rebellion, there was birth time. And I personally love how well the creators of this documentary have been able to encapsulate how meaningful great maternity care is to women. So birth time represents the type of care that I received in my own birth and the type that I I've been giving to women throughout my career as a midwife and all of the things that women deserve in their pregnancy.
[6:48] Birth and postpartum care.
[6:50] BirthTime has won 22 international film awards and has created a tangible shift in the birth culture with its powerful storytelling. It showcases some of the biggest problems in maternity care, but also showcases all the solutions. I love that it's not just about home birth, it's about continuity of care and women having great births wherever they choose to go. So if you are pregnant or just coming into the birth world now and exploring your options as a new midwife, a newly pregnant woman.
[7:24] Student, obstetrician or doula, and just discovering all of the resources that are ingrained in the maternity care landscape, if that's you, I need you to know that Birth Time, the documentary, is a not-to-be-missed resource. It's going to help you get the best out of your pregnancy birth and postpartum journey and the birth time team are offering 20% off at the checkout for Great Birth Rebellion listeners so all the details are in the show notes if you love the Great Birth Rebellion podcast you will love the birth time documentary so click the link in the show notes to access your discount okay let's go we're going to start with what is an obstetrician now I did try to find a clear definition of an obstetrician, actually, I thought it would be easier. And I started at the Royal Australian and New Zealand College of Obstetricians and Gynecology, RANSCOG. I started at their website, But a clear definition was not forthcoming on their website. So if someone finds it, do let me know. But I ended up turning to Gemini AI, which does the trick for these kinds of more simple questions. And I asked it. This was the prompt. What is an obstetrician? And it said, an obstetrician is a medical doctor who specializes in pregnancy, childbirth, and postpartum care. They provide comprehensive medical management for both mother and baby from preconception to post-pregnancy.
[8:52] Specializing in navigating high-risk pregnancies and managing complications. And when I read it, I thought, yep, that sounded about right to me. That's what I would have plucked out of my own head had I decided to go with what I already knew about obstetricians. But AI agrees they are medical specialists who provide medical management and specialize in navigating and managing complications. And we're very grateful for that. The internet offered some other helpful definitions of what an obstetrician is and what their role and scope is in maternity care. And one website explained that an obstetrician is a doctor who is trained to offer antenatal care, so that's pregnancy care, care during labor and birth, including interventions and cesareans and postnatal care. And most obstetricians or many obstetricians are also trained in gynecology. So some people call it OB slash gynae, so obstetrician and gynecologist. And Wikipedia says that obstetrics is a field of study concentrated on pregnancy, childbirth, and postpartum. It's a medical specialty.
[9:59] And in some jurisdictions is combined with gynecology, which is typically a surgical field. So I don't think anyone would argue that obstetricians are doctors involved in the medical management of pregnancy, birth and postpartum with particular skills in assisting with complications. And I want to underline that they have skills with complicating factors and the medical management of pregnancy, birth and postpartum. And I know there are some obstetricians listening and some people listening, feeling that maybe I've left out part of the scope of obstetricians. And I know that many obstetricians, particularly those working in private practice and in medical maternity care models, they often busy themselves with caring for well women who have no medical need for their services. And they might have a social, emotional, cultural, or psychological need for a medical person to be involved in their care. So, while it's true that obstetricians do care for well women, we must remember that obstetricians specialize in the medical management of pregnancy, birth, and postpartum care. And for most women, pregnancy, birth, and postpartum is not an actual medical event. So, we're getting medical care.
[11:15] For a non-medical event in many circumstances. So they are doctors with a specialty in medical management. So it's true that obstetricians have expanded their grasp over the care of women that are well and healthy and low risk. And the type of care that they're trained to provide is rooted in a medical philosophy. So there's a disconnection there where pregnancy, birth and postpartum aren't always an illness, yet it's come into the jurisdiction of medically trained clinicians and there are some brilliant obstetricians out there who have taken it upon themselves to understand and support physiology and physiological birth and well healthy pregnancies but these are few and far between so I would caution you to assume that just because you yourself or you yourself are an obstetrician who is physiologically minded, or if you're a woman who's had great care under the care of an obstetrician and feel like what I'm talking about does not resemble the experience that you had, I need you to know that you are in an unusual scenario.
[12:25] It's great, but that's not the case for everybody.
[12:30] So before answering the question of when do you need an obstetrician, let's just first answer the question of when do you not need an obstetrician? If you speak to some people, they'll say a doctor or obstetrician is needed at every birth, just in case something goes wrong.
[12:46] But what we know from research, which I will talk about, is you don't need an obstetrician to keep you safe if you are experiencing an uncomplicated pregnancy or birth. And it is true that things can become complicated at some point, but you do have care under the care of a midwife. And that is our job is to care for you while you're well, identify when things are not going well, and then invite other more specialist care providers into the space, into your care to help manage complexities if and when they arise. But you don't need medical staff hovering around on the off chance, on the instance that things go wrong.
[13:30] So if everything is fine and your midwife is there and she is skilled, you will never need the involvement of a doctor in order to keep physically safe if you remain well yourself. And I can say this because around 80% of my clients never, ever need the involvement of another care provider other than me and my midwifery colleagues. For women who have uncomplicated pregnancies, births and postpartum, it is completely fine, safe and appropriate and evidence-based to only have the involvement of midwives in your care. This is an appropriate model of care. and some women do develop complications and then we need to include other care providers but the majority of well women will never need the involvement of a doctor in their care because midwifery care is enough in order to maintain physical safety for yourself and other realms of safety of course and for your baby but.
[14:29] I'm not just telling you this from my experience. It is my experience that there is a lot that falls within the scope of midwifery, that we don't have to invite other specialist care providers into the care of every single woman. But let's have a look at what the research says. So if we have a look at this paper, which was released in 2024, so nice and recent, and it's called Midwife-Led vs.
[14:53] Obstetrician-Led Perinatal Care for Low-Risk Pregnancy. And it's a systematic review and meta-analysis of 1.4 million pregnancies. And actually, this one is available in full text in the resource folder for this podcast. So if you're new to the podcast, we have a resource folder which is full of all the research papers that I use to make every single podcast episode, right, right, right to the beginning of episode one. So if you want to get access to all the research papers that I use to create every single podcast episode. They are all available to anyone who's on the podcast mailing list. So you can read them for yourself. Just go to the show notes below, click the link to join the mailing list and the resource folders will come straight to your inbox and you can access them anytime. And you just click a link in the email. It's updated every week. So you'll get all previous episodes and all free future episodes as well. So the authors of this study said that they started off their paper saying the optimum model of perinatal care for low-risk pregnancies has been a topic of debate.
[16:00] Obstetrician-led care tends to perform unnecessary interventions, whereas the quality of midwife-led care has been the subject of debate. And this review aimed to assess whether midwife-led care reduces childbirth interventions and whether this comes at the expense of maternal and neonatal well-being, because that can be the argument sometimes. People say, well, yeah, there's less intervention, but maybe that leads to poorer outcomes. So that's what this paper was trying to discover. And the paper was a systematic review and a meta-analysis, which means they didn't do their own research for the paper. It's a collection of existing literature. Which I love because that means I don't have to run about and dig up all the papers that compare midwife-led care to obstetric-led care. So these authors have done it for us very recently in 2024.
[16:53] So they included 44 studies and when they pulled the amount of women that were in the studies, it totaled to 1.4 million women. And they found that midwife-led care carried a lower risk of unplanned caesarean section and instrumental vaginal birth. So that's including forceps and vacuums. There was less augmentation of labor. So the use of artificial oxytocin during labor. There was less epidurals, less episiotomies, and they required less active management of the placental birth. So a lot more of them had physiological placental births.
[17:31] From this study, we know that the women who receive midwife-led care had a shorter hospital stay, a lower risk of infection, less chance of their placenta needing to be manually removed from their uterus, less chances of requiring a blood transfusion, less chance of being admitted to intensive care unit. And also the babies born under midwife-led care had lower risk of acidosis, which means they were less likely to be low in oxygen at birth, less likely to have asphyxia, less likely to be transferred to special care or the neonatal intensive care unit, less chance of postpartum hemorrhage, less chance of perineal tears. The babies were less likely to have an APGAR score of less than seven. And the outcomes were comparable between the two models of management. So based on this systematic review of 1.4 million women they concluded that midwife-led care reduced childbirth interventions with favorable maternal and neonatal outcomes in most cases so based on their findings they recommend assigning low-risk pregnancies to midwife-led perinatal care in healthcare systems with an infrastructure allowing for smooth transfer when complications arise.
[18:48] And that's what we're talking about today. It's starting your care with a midwife. And then if complications arise, that's the time where we need and use obstetricians because they're highly skilled, trained medical professionals. So there you go. It's not just my experience or opinion. 44 studies, including 1.4 million women, came to the same conclusion. Start with midwifery care, go
[19:19] from there for best outcomes if you're experiencing a low-risk pregnancy. So what we know from this research is that women with no clear medical needs and their babies fare better than low-risk women who are cared for by an obstetrician. So you're actually improving your own and the outcomes for your baby by choosing midwife-led care rather than opting for medical care if you don't have a medical need.
[19:46] So it's evidence-based to prioritize midwifery care for low-risk women over obstetric care. And these types of studies and findings is why I keep saying these things. Low-risk women and babies are safer under the care of a midwife, statistically speaking. And I don't say that because I'm a midwife. I say it because that's what the evidence has shown us over and over again, that midwives are experts in supporting birth physiology and midwifery care is better suited to low-risk women because it has better outcomes than obstetric care for low-risk women. And if you want to argue against that, I do welcome the research papers if you want to send them over because I didn't find any. You will hear at the end of this podcast, there is one single paper that is a little bit controversial and doesn't say what I just said there, but wait till the end. We can discuss that. And there is a whole podcast episode on that one paper. It's episode 161, but we'll get to that discussion.
[20:48] Now, I know there are other reasons, not physical safety reasons, why women will choose obstetric care, even if they have no medical need for one. They might feel really scared and they might actually feel safer under the care of an obstetrician for those just-in-case scenarios. Maybe they don't trust that midwives could provide care to low-risk well women and they're frightened of the time that things might become complicated.
[21:16] Little do they know and maybe they do i don't know but you're actually more likely to to experience one of those emergencies or a poorer outcome an increased you, interventions if you're a well woman and you do choose obstetric care. And I will support that claim with a research paper. So the other reason why women choose obstetricians without an actual medical need is that they have private health insurance and they just want to use it to justify the cost of having maintained it for so long. But if you're in the US, for example, the whole maternity care system is centered around obstetric dominance. So it can actually be tricky for women to avoid an obstetrician and there are a range of reasons why people choose obstetric care even if they don't medically need one. And if you've consciously chosen that and you are comfortable with your decision and you believe it's going to be the best and safest for you, then you do need to persist with that because you've made that conscious decision for reasons of your own.
[22:18] And so to some women who are listening, you might feel judged for choosing an obstetrician? That's not my intention today. The intention of today is to practically and factually list out the medical reasons that an obstetrician would be a good idea to add to your care team. And I know that many women want a doctor to care for them, even in circumstances where they don't actually have a medical need for one. And there's a raft of reasons why they do that. It's a topic for a whole other day. So if you feel offended by this episode, I'm not taking responsibility for that. I'm not here to nurture delicate feelings. I am a digital voice in the ether and you can't expect me to be able to cater to the feelings and responses of every single listener. So I'm here to give you information that might help you make informed decisions and it's your responsibility to manage how you receive it and use it. So if you're confident that you've made the right decision for you and that you made it with a fully informed reasoning, this episode isn't for you. You've already got all the information you need to make an informed decision. You've made a confident decision and go forth with that. This episode though is for women and families who still want to learn more about.
[23:33] What the right and appropriate time is to include an obstetrician in their care and some women want an obstetrician and some women actually need one but don't want one so the two things are different and I'm here to talk about the times when you might actually need one and this might also help answer questions for you if you receive medical care that you believed was unnecessary or medically unnecessary this episode might help you to answer questions about whether or not your scenario did warrant the care of obstetric care. And I know we're quite the way into this episode already, but before going forward, I do feel obligated here to share my personal position on the role of obstetricians in maternity care. And if you heard episode 166 of the Great Birth Rebellion podcast, which was the ode to the late obstetrician, Michelle O'Don, you know that my position on the place of obstetrics aligns very closely with his. He was an obstetrician so this won't be new information to you if you heard episode 166.
[24:37] So Michelle O'Donnell was an obstetrician who advocated for the advancement and celebration both what he called authentic midwifery and of authentic obstetrics. Michelle believed that obstetricians were trying to lay claim over the full pregnancy and birth experience of a woman as primary caregivers and it's had this side effect that obstetricians are no longer reliable clinicians in pathological events because their time is not spent in honing these skills of dealing with complexity because they've busied themselves with the primary care of well women and there's certainly a conversation going on these days about the de-skilling of obstetricians, where many are no longer confident or capable of managing things like vaginal breech births, vaginal twin births, the skilled use of forceps, or manual rotation, for example. And there is talk of obstetricians.
[25:35] Inadvertently, I don't know, intentionally replacing those emergency skills which used to be in their scope to the overuse of cesarean sections. It's one reason why the birth societies believe that cesarean sections are on the rise is that there's actually a de-skilling of obstetricians in other hands-on surgical and technical skills. So Michel O'Donnell hinted at the de-skilling of obstetricians in his work and he called for them to focus on emergency skills in alignment with their scope and training as medical doctors. Michelle describes this birth utopia where the highly trained expert obstetricians of the future will have no time to control every single birth because they will be at the service of midwives and women and will only appear on demand as the situation requires it. Those are not my words. They are Michelle O'Donnell's words. Obstetrician.
[26:34] So as an obstetrician, he advocated for the expertise of obstetrics. He suggested the obstetricians stick to getting really good at managing emergencies.
[26:45] That's their job. Be experts at that and leave the care of well women to midwives. In Michelle's birth utopia, there would be a reduction in the number of obstetricians and that would be met with an increase in the number of midwives, which coincidentally now in this modern age, the World Health Organization is asking for an increase in midwives to help meet the needs of women and the International Confederation of Midwives is petitioning government for one million more midwives, which is what we spoke about in last week's episode.
[27:18] So in this utopia, midwives would be very good at nurturing women through physiological pregnancy, birth and postpartum. That's the authentic midwifery part And the obstetricians would be ready to serve women and midwives with their expertise in the event of emergency or complication. That's the usual order of operations that Michelle O'Donnell would suggest. And that would be the side of the fence that I sit on too. But it's not the current case in maternity care. This utopia is not realized. so you will at many points in your maternity care as a well woman without complications have medical appointments with doctors and obstetricians and these are thrust upon you because they're built into the medicalized maternity care system and doctors and obstetricians are still or are currently the gatekeepers of maternity care for all women.
[28:18] So how do you know if you're getting medical care because you actually need it or if it's just out of systematic procedure and for the purpose of this medical gatekeeping and control over midwifery and women and birth? So let's have a look now in which circumstances you need an obstetrician in order to experience better outcomes. So firstly, you need an obstetrician if or when you develop a pregnancy, birth or postpartum complication that is outside the scope of your primary care provider, who I hope in Michelle's utopia is a midwife who, you know, they could be a nurse midwife, midwife or GP, depending on where you live and what you have access to. So nurse midwives, midwives and GPs can help with primary care of well women. Remembering though that GPs are also medically trained care providers they aren't.
[29:15] Maternity care specialists of well women in the same way that midwives and nurse midwives are. And then if there's a complexity, these primary care providers will refer you to or consult with a specialist doctor who can help with managing a complication or risk. So for pregnant women and birthing and postpartum women, your specialist doctor is an obstetrician. So I will say here though, there are complications that occur that don't involve the requirement of an obstetrician specifically. Some complexities can be managed by midwives depending on their scope or another specialist entirely. It might be a haematologist or an endocrinologist or some other specialist depending on the complication. It doesn't always need to be an obstetrician. It really depends on your circumstance. So in here in Australia and overseas, they'll have a similar document, I suppose. Midwives have the consultation and referral guidelines, which are a document.
[30:20] That have been mutually agreed by the Australian College of Midwives and RANSCOG, which determines under which circumstances a woman requires consultation or referral to an obstetrician or another medical specialist. So there are guidelines for this for midwives. Under which circumstances should you involve another care provider in this woman's care? And they have defined our scope of practice, which can be individual to each midwife as well, depending on their skill and experience level. So if a woman requires care that is beyond the midwife's scope, that's a clear indication for consultation and referral to an obstetrician or medical specialist. It's as simple as that. If the midwife doesn't know what to do next for you, you need the next person in the specialty, which is an obstetrician. So this doesn't mean that you depart from your primary care provider. They keep caring for you.
[31:16] You just add another health professional to your care team and they work in consultation with each other for the betterment of the care that you need. It's not one or the other. Women with more complexities usually require more people in their care team so that all their needs can be met. And this starts with the primary care provider who specialises in the care of well women and then it expands and extends to include specialists as needed. So a pregnant and birthing and postpartum woman isn't immediately sick. So she doesn't need medical supervision from the beginning just because she's pregnant. But if she does become unwell, it's a clear reason to involve some form of medical assistance.
[32:02] Now I know so far we've been talking a lot about.
[32:05] Low-risk women. But this continuity of care with a midwife thing that I'm talking about, it even works for women who already have complications or those who develop complication. So there was a randomized control trial that was published in 2013. It was called the Mango Trial by Sally Tracy and her team. And they wanted to see what the outcomes would be for women and their babies if midwives cared for women who were high risk. So these women would have normally been given the standard care in the hospital system, which usually is just the obstetric clinic, and they wouldn't have had high level of involvement from midwives. So they did this study. They wanted to find out what would happen if women who had high risk, were at high risk of complications, started in continuity of midwifery care. So they made caseload midwifery models available to women with risk factors to see what would happen with the outcomes. So then they compared the midwifery caseload model to the usual standard care that the hospital would have given women. And as I said, that usually involves just being put in the obstetric clinic and being cared for by doctors.
[33:19] They wanted to see what the difference would be. And they found that some outcomes were better in the midwifery model and all of the more serious physical safety concerns that we have for women, all of the serious outcomes for women and their babies remained relatively unchanged and the same across both groups. So regardless of whether the woman was in the midwifery model of care or obstetrics, the major health outcomes were no different. So what they found is they can provide equivalent care, except the midwives could get the same outcomes as standard obstetric care for high-risk women, but for $566 cheaper per woman. And when they interviewed the women about their care, the women were more satisfied in the midwifery group and the breastfeeding rates were better.
[34:13] So same outcomes, you know, basic physical outcomes for high-risk women for less money and the women preferred the midwifery model. So that just goes to show that while we do need obstetricians to care for women with complexities, they function better as valuable additions to a care team rather than the primary care provider. And certainly when the midwives are looking after the high-risk women, this was the situation. Is that the midwives would care for them and if and when they needed obstetric input that was available so both together was a better scenario than obstetric care alone for low-risk women yes we know that for sure but the mango trial showed that this these outcomes can also work for high-risk women.
[35:05] So it's definitely true that sometimes you need obstetricians to help with rescue medicine and emergency management, but at other times they can provide care that will prevent an existing complication from escalating to an actual problem. So they can help manage a risk factor so that it doesn't become an actual real complication. So that's the other role of obstetricians. And that's the broad answer of when do I need an obstetrician but we can have a look now at some specific circumstances where it would be wise I guess to and you know result in better outcomes if you include an obstetrician in your care team. So while I mentioned before that the most ideal order of operations would be that you have a midwife as your primary care provider and then add other specialties as needed. This may work the other way around for women who have known medical conditions. So you may be offered obstetric care based on your individual health needs or you may choose to hire an obstetrician based on what you know about your health needs. And if that's the case, the next best scenario, if you can't have a midwife as your primary care provider.
[36:21] And you do need to hire an obstetrician. There are obstetricians who hire midwives to also be part of the woman's care because they recognize that midwifery care is valuable. So midwifery services and obstetric services are very different. We both care for pregnant, birthing and postpartum women, but our services are different. An obstetrician can't give midwifery care in the same way as a midwife can't give obstetric care. Lots of obstetricians are aware of this and to enhance the care of women who hire them, they also include midwives in their care team. So this is a good scenario. If you want to know your obstetrician because you have some complexities and you want to navigate that with a single known person, then you could potentially choose one who also hires midwives in their services. This is a good scenario for women who have highly complex needs. And I was speaking, I'm not going to name her, but I was speaking to an academic colleague of mine. You would know if I mentioned her by name, but I don't want to implicate her in this conversation. But I was speaking to her about this one day about how it's good that you know these obstetricians are realizing the value of midwifery care for all women and they're hiring them and she said yeah but.
[37:46] But really, it should be the other way around, that women hire their own private midwives and then the midwives are employing obstetricians to help them look after their clients. And I thought, oh my gosh, yes, that scenario would factor into mine and, I mean, Michelle Odot's utopia. So if I got a chance to reorganize the maternity care system, unfortunately I don't, but that would be the way around that I would do it. It's that all women get a midwife and then there's obstetricians involved in their care as needed and they're hired by the midwives instead of obstetricians hiring the midwives. Anyway, that's just me dreaming. Unfortunately, women didn't get to organize maternity care. In fact, rich male obstetricians did. It's just a historical fact.
[38:40] Men designed the maternity care system. But anyway one day we'll have turned around the dial enough that the maternity care system that cares for women will be designed by and for women but that's not today so that's what we're working with all right I've ranted long enough about that so let's look at some of the pregnancy circumstances that.
[39:04] Without a doubt, without medical involvement, your outcomes would not be so good. So firstly, let's start. We'll go pregnancy, birth, and postpartum. So firstly, during pregnancy, if you have a serious pre-existing medical condition that already requires ongoing medical management or medication that needs supervising, you may choose to engage with an obstetrician as your primary care provider, and hopefully they also have midwives in their offices so you don't miss out on midwifery care because this is the biggest disservice done to women particularly in the public maternity care system is that if you have complicating factors or risk factors you get medical care but you don't get any midwifery care but all women deserve midwifery care and some of them need obstetricians so they will in a public system automatically refer you to the obstetric clinic if you have risk factors but and I said it before and I'm going to say it again obstetric care is different to midwifery care and just like obstetricians can't provide midwifery care midwives can't provide obstetric care neither provide the same service as each other so for women with complications both midwifery and obstetric care is needed and some of because you know the more complications you have, the higher your needs. You should have more care providers.
[40:27] And so some of the more serious pre-existing conditions include things like autoimmune conditions, heart conditions, unstable hormonal conditions such as thyroid diseases that haven't been controlled, uncontrolled diabetes. Those are a few examples. If you have some of these more serious conditions under control, you could potentially potentially, It's not necessarily a volatile situation. You would definitely have some kind of medical input into your pregnancy in order to keep managing those. But I've certainly cared for women with controlled things like controlled thyroid issues or controlled diabetes quite confidently as a midwife. And then we review with medical professionals at points in the pregnancy. It's not like they require continuous ongoing care with a medical professional like that. There are also some inflammatory bowel conditions, existing cancers, blood disorders and infectious diseases such as hepatitis and HIV, and some serious neurological issues for the women. So that could include things like epilepsy, particularly if these are active and acute. It might be different if you know your health condition well, you've got regular care providers, and your serious medical condition or medications are well managed. And you can navigate that with your current care providers.
[41:55] And certainly things like for women with serious mental health issues who are on medications that maybe aren't suited to pregnancy. I've cared for women like this as well. And we've navigated that with their current health care providers and worked out a way to navigate their medications during pregnancy and birth. Under no circumstances did they need obstetric care though because they were otherwise well. It was more about managing those medications in that way. So that's the first reason. If you have serious pre-existing conditions that are already being managed by a medical team, you will also need to continue to include a medical specialist in your pregnancy, birth and postpartum team. And that could be an obstetrician. They don't replace your midwives, but they are a necessary addition.
[42:43] The other reason that I would encourage you to include an obstetrician is if you have a history of repeated early pregnancy loss and difficulty with things like preterm birth due to issues with your cervix. So some women who have repeat early or late term miscarriages might find a solution to this in some early intervention with an obstetrician. And this could include progesterone pessaries, cervical stitch, early monitoring. you might discover that you have some gene indicators so the MTHFR gene and you can have some appropriate management for that. You might have a condition that requires you to have early aspirin administration. So depending on the reason for the early losses your obstetrician can put in a plan to increase the chances of you maintaining future pregnancies to full term.
[43:35] So definitely if you're pregnant and you've had issues with repeat early pregnancy loss, an obstetrician can help you discover why and strategize for a management plan. And this could include things, you know, even if you discover on ultrasound that you have shortening or funneling of your cervix, or if your cervix is prematurely opening, you will have better outcomes if you include an obstetrician in your pregnancy.
[44:02] The next thing with regards to pregnancy involvement is if you have an ectopic pregnancy. This is a medical emergency and an obstetrician would be involved with this along with the rest of your care team. There are other complications, for example, placenta previa, where the placenta is positioned completely over your cervix. If it doesn't change position through your pregnancy and it remains complete, placenta previa doesn't need intensive management all the way through your pregnancy. However, women with complete placenta previa are prone to bleeding events during pregnancy and they do require a cesarean section in order for their baby to be born alive. So while you might not need an obstetrician throughout your whole pregnancy you are at risk of extra complications so it's good to involve them early in the early planning of that and the ease of transition in the events of early bleeding and also for birth planning and birth timing because the cesarean sections for these are a little bit more complicated and they might require a bit more strategizing.
[45:09] Okay the next reason to include an obstetrician in your care is that If under ultrasound, an anomaly is noticed in your baby, it might need extra monitoring and extra planning. So from real life circumstances, I've had clients who've discovered that their baby had heart defects or major organ defects. And on more than one occasion, this has sent us on a journey of discovery to understand the extent and type of defect and how soon the baby would need medical attention after the birth, what type of birth planning we would have. Do we need an induction, caesarean, or can we continue with a spontaneous birth? And, you know, I'm a home birth midwife, so we have to make decisions about appropriate birthplace. So a number of my clients have persisted in planning home births for their baby with known heart defects that were considered more minor, and others did birth in hospital because it was anticipated that the baby would need immediate assistance after birth.
[46:10] In all cases, whether or not where we gave birth was irrelevant, but an obstetrician was involved in the monitoring and planning during pregnancy and birth. So that would be another reason. And if you are a mum and you're pregnant with twins or multiples, while you are not necessarily in a high risk situation, it is possible to have an uncomplicated pregnancy with multiples. They do require some skill in monitoring and management so just even understanding what type of twins or triplets you have how many placentas are there you know all these little little intricacies so it's it's not easy to determine which multiple pregnancy will be complicated and which won't there are lots of different types lots of different types of complications that can occur there's lots of scenarios where everything also goes completely fine but an obstetrician in collaboration with midwives is a helpful specialist to have involved in these pregnancies.
[47:18] Be aware, though, that not all obstetricians have equal skill sets. While they all can help with a twin pregnancy or pregnancy of triplets, not all are supportive of twin vaginal births, for example. Some may have a policy of early induction or cesarean as standard for twin pregnancies. So if you're pregnant with more than one baby and you want a vaginal birth or you want to avoid an induction or a caesarean, then you need to be really specific with which obstetrician you choose. While I do believe that pregnancies in multiple babies would benefit from obstetric oversight, be cautious about which one you hire so that they actually match the type of care that you want. And although they're supposed to have these comp skills in more complex vaginal births, like multiple babies and in things like breech, there is this collective de-skilling of obstetricians. And as a result, many may not be confident with these more complex skills with the birth of multiple babies, and they will favor a known scenario like a planned caesarean over the more unknown scenario of a planned spontaneous vaginal birth, which may or may not include a breech baby.
[48:42] And also some will prefer that you have an epidural during that vaginal birth because that's their comfort levels.
[48:49] So you need to ask some pretty straight questions, things like, what is your usual birth plan for women with twins? What would you do if one of them was in a breech position? Would you be requiring me to have an epidural if I do choose to have vaginal twin births? Do you even do vaginal twin births? So ask them these kinds of questions. You can let them know what your preferences are and ask them if they are confident that they have the skills to provide that for you. And if not, that's okay. And be grateful that they told you the truth and that they were honest with you about their confidence levels. You can ask them to refer you to a clinician who does have the skill that you desire. There's nothing worse than asking all of these questions only to discover that your care provider had no intention of actually fulfilling the desires that you had because maybe they don't actually have the confidence, but they were hoping that they could change your mind at the last minute. Some people call that the bait and switch.
[49:48] They reel you in and then while you're too far into care to change,
[49:53] they reveal their intentions the whole time. Now, the other reason you might need an obstetrician is that you have newly diagnosed illnesses in pregnancy that may need to involve an obstetrician, depending on what they are. Sometimes with complications, all it takes is one or a few visits to understand your unique needs and strategies. So not everything requires ongoing care with an obstetrician. Some things just may require a few consultations, for example, and then you can continue on with your plan. So I've had clients, for example, who've had a sudden unexpected bleed during pregnancy. That's an immediate and unusual circumstance with their pregnancy. Off we go, obstetric. Management, obstetric assessment, and they found the cause, they go, okay, this is the cause, come back if this, this, and this, and this, and then we continue on with care. So it really is about in circumstances where something new has developed that is a complication, seek out some specialist obstetric care. You may need to continue with that if it's an ongoing issue, or it may be resolvable, and then you resume regular programming.
[51:04] So also think about things like gestational diabetes, for example. So whilst this is a complication, many midwives have the ability to refer you for diagnostic testing, assist with diet changes and lifestyle changes, show you how to monitor your blood sugar levels. They know what's a normal blood sugar level and when to refer on if the blood sugars are not controlled. So I know for myself, I've helped enough of my clients navigate gestational diabetes that I've developed an expertise.
[51:37] And now in the event of diabetes, I have the skill and capacity to send them for testing for diagnosis and then help them with their diet and management without any medical involvement. it. So my capacity goes that far, but not every midwife would have the comfort with that. And then, of course, if everything that we've tried isn't working, I've reached the end of my scope, it's time to involve an endocrinologist, an obstetrician, whoever else we require as a specialist care provider in that scenario. The other thing, things like urinary tract infections, It is a complication, but a skilled and autonomous midwife can send away for testing and recommend and monitor treatment for a urinary tract infection without medical involvement, particularly here in Australia for an endorsed midwife. You can prescribe antibiotics. You can get pathology testing. You can monitor the seriousness. You can check the woman's observations. You can manage the complication. But certainly if after you've reached the end of your scope if things aren't improving it's time to refer on.
[52:50] So, okay, the next reason why we might include an obstetrician, if there's abnormalities noticed on ultrasound, these will always be reviewed by an obstetrician and then ongoing consultations and recommendations might be made based on the findings. For example, is the amniotic fluid too high or too low? Does your baby appear to be growing abnormally? Is there a problem with the placenta or the blood supply to the baby? Now, two other complications that need the involvement of an obstetrician. Is cholestasis which is a liver and gallbladder issue and preeclampsia or eclampsia and help syndrome. There are some difficult decisions to make about the type and length of treatment and management of these conditions and an obstetrician can help to decide when
[53:40] the ideal time of birth would be based on the circumstances. So with these conditions it's about if there's this balance between keeping the baby in as long as possible without the woman or baby's health being compromised. So we're constantly watching if things are escalating, if they're stable. It's a, you know, it's a kind of an every other day or every day checking in. So it's quite a, I guess, acute situation, intense situation.
[54:08] The only solution for these things is for the baby to be born. Without that, they don't resolve. And in fact, preeclampsia can get worse postnatally. So it requires ongoing monitoring. They can be stable, but they need close monitoring. They don't resolve. It's an indication to include and keep an obstetrician involved in the care. There are other things such as some infectious diseases that are dangerous to babies, including CMV, which is a cytomegalovirus, genital herpes, especially if it's a first event. So these kinds of infectious diseases, again, the involvement of an obstetrician. Things like placental emergencies, such as a placental abruption, or if there's clearly diagnosed placental insufficiency. This is a time where you would involve an obstetrician. These are emergencies. Now, the next things. Other things. Kidney infections. We kind of spoke about that a little bit. Acute medical events or accidents.
[55:08] Unexplained blood loss in pregnancy. These are all reasons why you need to go get checked out by an obstetrician. Now, let's talk about breech positioning during pregnancy. Now, breech is becoming a midwifery skill. Many places around the world, midwives have been expected to delegate the skill of vaginal breech birth to obstetrics. However, in this day and age where obstetricians have relegated the responsibility over breech births, they've just decided, the majority have decided that breech gets caesarean sections.
[55:50] Midwives are clawing back that skill. But in the event that your baby is breech, the maternity care system would expect that an obstetrician would become involved in your care, either in the use of an ECV, external covalic version, where they turn your baby back to a head down position, or in the planning of a breech birth. So in those circumstances, at the very least, you would include an obstetrician. All right, so that was pregnancy. now let's move on to birth remembering that if everything is normal and well you do not need an obstetrician they are medical and emergency specialists whose best work is done when there's a complication or in anticipation of one not every pregnancy birth and postpartum event is an emergency and I know that that's.
[56:45] Not new information to you who's listening but the maternity care system does believe that your pregnancy birth and postpartum are a medical event always at risk of emergencies that's why they always include obstetricians but the research says that's not needed. So inviting an obstetrician to an uncomplicated birth is like inviting your GP to your birthday party it might be nice to have them there if you like them but there's nothing for them to do because there's nothing wrong.
[57:15] So midwives and nurse midwives are the trained health professionals whose role and responsibility it is to support women through uncomplicated labor and birth and then we call a specialist in in circumstances that exceed our scope and expertise so just like we are not the ideal care providers in a true medical emergency obstetricians are not the ideal care providers during an uncomplicated birth but we do need them for some circumstances and they would include planned elective cesarean section. Midwives can't do that. You need an obstetrician. If you need an emergency cesarean for things like cord prolapse, confirmed fetal distress and I'm acknowledging that this is very tricky to diagnose, placental abruption, intrapartum hemorrhage, so if you start bleeding during your birth, things like uterine rupture. We need obstetricians for emergency caesareans for true emergencies. If you're having an induction or an epidural, you are now entering into the realm of medicalized birth and these require medical management and oversight.
[58:28] So then we do need to include both midwife and obstetrician. In the event that your birth actually becomes medical through the use of induction or an epidural, you now invite medical specialists into your care.
[58:43] Again, as we already spoke about, twin vaginal births, while it's true that midwives have some skill in vaginal twin births, again, only in the instance that everything is going well and normal. We are capable of caring for a woman who's having a twin vaginal birth where there's no complications. In the event that there are, we involve an obstetrician. Again, breech births, although that one's a bit controversial because a lot of obstetricians have fewer breech skills than a lot of midwives. There is a circumstance involved in birth called deep transverse arrest where basically the baby's got itself well and truly wedged in the woman's pelvis either due to malposition or for some other reason. This is a type of obstruction in labor and we certainly need an obstetrician to help with that. Sometimes manual rotation can be helpful. Things like vacuum, forceps, particularly with a persistent OP baby.
[59:45] Doing a manual rotation of one of those babies is an obstetric skill, but also midwives, we can do manual rotation. However, I guess we're not really that used to having our hands inside a woman so intensely, but obstetricians are. So if they've got that skill, fantastic, leave it to them. Obstructed labor needs medical management. And certainly in lower and middle income countries, obstructed labor can be a significant reason for the damage and death of babies and mothers. Again, if you need an instrumental birth with vacuum or forceps, that's an obstetric job. Then big and rare emergencies like amniotic fluid embolisms, 100% medical event, very life-threatening. We need doctors to assist with that. Any change in the mother's vital signs, so suspected infections, blood pressure issues, whatever they may be.
[1:00:44] The other one during birth could be retained placenta. So if you've tried everything as a midwife to try and get that placenta out and it's not going to come out, then an obstetrician may need to assist with that either in the room or in the operating theater. That's a list of things where I believe definitely you need obstetric care. There are other complications that maybe don't need obstetric care that can be managed by midwives. But if you feel like I've missed something, please do always message me. I am so available. You can email me. If you're on the mailing list, you'll actually have my personal and direct email.
[1:01:23] And message me on social media. I would be keen to know if I've really missed something here for birth. But we'll move to postpartum.
[1:01:32] So after the baby is born. if the woman's having a significant postpartum hemorrhage either immediately after or so if it's a primary or secondary postpartum hemorrhage any kind of postpartum infection or sepsis repair of third or fourth degree tears and incontinence management if that should occur there are some major mental illnesses and mental disturbances that can occur postpartum including psychosis in which time you do start to involve medical care providers this is a medical circumstance. For women, if you've experienced preeclampsia, eclampsia or high blood pressure during pregnancy, these need ongoing care and monitoring with obstetric care because these can actually become worse postnatally than they were during pregnancy. So don't relax on the care for women who have preeclampsia. Postpartum is generally their more risky time.
[1:02:25] There's also something called post-dural headache, which is basically an extreme headache that results from an epidural. You need to involve an obstetrician in this. There are medical ways that this can be managed. Things like blood clots, prolapses. You need obstetricians to review surgical outcomes and any postpartum medication that needs administering is first reviewed and prescribed by an obstetrician most of the time.
[1:02:56] Now that we've been through that list of absolute doom and gloom gosh I hope that I didn't make you feel like any of those were inevitable for you they're certainly not it's entirely possible to remain healthy all the way through your pregnancy but when they're all collected together like that and listed out it does sound dire but I can assure you that your pregnancy birth and postpartum journey is far more likely to be medically safe and medically uneventful than to be complicated and fraught. But to you who have had a scary pregnancy, these are the times that we are grateful for the skill and talent and profession of obstetrics.
[1:03:38] Okay. Now, as we come to the end, let's have a chat about how to access obstetric care. And I fully acknowledge that some women in some areas are over-serviced and have obstetric care embedded into their care, whether they ask for it or not. And in this case, this is like similar for if you've got on a midwifery caseload program or a home birth program, women have to run this gatekeeping gauntlet where an obstetrician is given the job of screening women to determine if they're allowed access to midwifery models of care in some kind of paternalistic act of dominance over women and over midwives who actually are completely capable of this job. And then many services will also require these women to see a doctor again at 36 weeks to decide if they're still suitable to remain on the home birth program or the MGP service for their birth care. So I have a lot to say about that. It's not for today. But anyway, some women are forced to receive obstetric care that they didn't want, that they didn't ask for, and that they didn't need. And then, conversely, others can't get access to it when they want it because of issues of cost, location. So there's this disparity between cities and rural areas and also across from country to country.
[1:05:02] So we'll try and speak generically about how to access obstetric care if you want or need it.
[1:05:08] Acknowledging that access is not equal and that you personally might not have easy access. But hopefully I can share enough to help you get started. So here we go.
[1:05:20] If you go to a public hospital and you're labeled as being low risk, you'll be put into a midwifery clinic or if you're lucky, you're offered an opportunity to have midwifery care, continuity of midwifery care. And then if you develop complications, your midwives will have a pathway to consult with a doctor or refer you for an appointment to them. And in this scenario, your medical needs will likely dictate your access to obstetric care. But if you go to a private hospital and you're labeled as having risk factors, they might not offer you midwifery care at all and put you straight in the obstetric clinic where you only see obstetric doctors for your care. And so while they can help you navigate medical complexity, they can't provide you with adequate pregnancy care in these circumstances. Even midwives struggle to give great care in these short little appointment times that they have and this issue is extenuated in obstetric appointments because they're not even trying to give you midwifery care because their job is to give you obstetric care. So women with risk factors are particularly vulnerable to missing out on midwifery care because hospitals will prioritize medical needs over the woman's preferences and social, emotional, mental, psychological needs. They will opt them out of midwifery care and only offer them obstetric care.
[1:06:44] That's generally how it happens in the public system. And if you want to select your own obstetrician, you want to know the person who's going to be caring for you, you have to hire a private obstetrician. And here in Australia, you either pay out of pocket for that or your private health insurance will, depending on your package, will pay some of that. So that's how you can get access to an obstetrician that you know. If you're going to a public hospital chances are that you will see a different obstetrician each time for your appointments and you won't know the person who's caring for you at the time of your birth it's just the reality of public care it's fragmented and so you see different people at different times so you do have the option if you find that you do need a private obstetrician that you need to have involved in repeatedly over your care, you could go on a journey to find one that aligns with your needs and who has the skills that you want. Okay, I know this has been a long episode, but there's one final thing that I want to talk about.
[1:07:52] The final thing I need to tell you is that if you want a low intervention vaginal births.
[1:07:59] Best chance of you getting that is under the care of midwives. We know with absolute certainty that obstetricians are medically trained specialists in emergency medicine and in the care of women with complex medical needs and they're less capable of providing low intervention care when you compare it to midwives. So if it's a low intervention vaginal birth that you want and you choose obstetric care, you may be making plans that will sabotage your own birth plans. There was a study done. It was all low-risk women, not women with complexities. And the researchers compared outcomes for low-risk women in private hospitals under the care of obstetricians to public hospitals, where low-risk women are generally cared for by a combination of care providers it is fragmented but this was the study the paper is called rates of obstetric intervention amongst low risk women giving birth in private and public hospitals in New South Wales and I'm using this paper to demonstrate some of the research behind that statement that I made that about low intervention births if you want less intervention you will not choose a private obstetrician in a private hospital because your best chance at that would be to go through a publicly funded hospital or better yet at a birth center or home birth but that's not the comparison we're making today.
[1:09:28] So this paper showed that when they looked at the outcomes of 691,000 births for women having one baby and who were at low risk of complications. So these are low risk women. These are not, you know, people often say, oh, if that's because private obstetricians look for women who are more high risk. No, these are the same types of women. So among low risk women, rates of obstetric intervention were highest in private hospitals and lowest in public hospitals. Low-risk women having their first baby and giving birth in a private hospital compared to a public had higher rates of induction. So in the private, it was 31%. Public, 23%. Higher rates of instrumental birth. Private hospitals, 29%. Instrumental birth is vacuum and forceps. If you go to a private hospital as a low-risk woman, 29% chance of vacuum or forceps versus 18% in a public hospital.
[1:10:28] Caesarean section, and it's the private hospitals driving up caesarean section rates, by the way. Caesarean section, 27% in a private hospital at the time of this study. For low-risk women, though, 27% of low-risk women had caesarean sections in a private hospital compared to 18% in a public. Epidurals, 53% in a private versus 32% in the public. Women who had babies before, so multiples, also had higher rates of these things. Higher rates of instrumental birth, 7% versus 3%. Caesarean section for second-time mums, again, 27%. Low-risk multiple, okay? If you're a midwife, low-risk multiple, 27% caesarean section rate versus 16% in a.
[1:11:24] Public hospital. Epidurals, 35% versus 12%, again, for women who had babies before. Episiotomies. If you had a baby before, 8% chance of episiotomy in a private versus 2% in public. And there were, you know, clearly now, lower normal vaginal birth rates. If you go to a private hospital, it was 66% versus 81% in a public hospital. What they also found was that as interventions were introduced during labour, the rate of interventions in birth also increased, which speaks to that cascade of intervention that we've spoken about so many times on the podcast, where one intervention has both an intended and unintended consequences. And interventions are then required in order to counteract the side effects of the previous intervention, and then the cycle continues. So in this study, among low-risk women having their first babies, if they gave birth in a private hospital, 15 women per 100 had a vaginal birth with no obstetric intervention. So 15 women in 100 had a vaginal birth with no obstetric intervention.
[1:12:40] Compared to 35 in 100 women giving birth in a public hospital. Now, some of you might be listening and thinking, that is still really low. And I agree with you. That's just the maternity care system. But just know that if you're low risk, you've got far more chance of having interventions in your birth, surgical interventions, medical interventions, if you go to a private hospital with a private obstetrician compared to a private hospital.
[1:13:06] So the authors concluded that low-risk primips, so women having their first babies, giving birth in private hospitals had more chance of a surgical birth than a normal vaginal birth. So of course, if you want a medical or surgical birth, this is good news for you. A private hospital with a private obstetrician is more likely where you're going to get one. But if that's not your intention, make a choice for midwifery care or public care as a preference. And some of you astute listeners if you've been around the podcast for a while and some of you astute readers will know that there was a paper released in 2025 called the maternal and neonatal outcomes and health system costs in standard public maternity care compared to private obstetric led care now this is where they were comparing the public system to the private system And it controversially concluded that there were higher adverse outcomes in standard public maternity care compared to private obstetric-led care.
[1:14:11] And it cost, this was the very funny part, what they found was that the cost of care to children, the taxpayer, was $5,900 higher in public maternity care compared to private. And what they concluded is that we've shown significantly lower adverse health outcomes and costs in private obstetric-led care compared to standard public maternity care. Now, we have to know that this was written under a circumstance here in Australia where private hospitals and private obstetric care is being increasingly challenged and private hospitals are closing down more frequently here in Australia. So this feels like a reflexive response to that. You'll also know that myself and Professor Hannah Darlan picked this paper apart in detail to determine its truth in episode 161. And we explored the nuance of the findings and I've linked that for you in the show notes So that you can listen to that one also, because I know that if you've been listening to this episode, you'll be saying, Mel, why didn't you have a look at that paper? And the truth is, is that we've already looked at that paper in an entire episode of its own. So have a look at episode 161.
[1:15:33] And if you've been following along on social media, at the time when I released episode 161. I also mentioned that one of the authors on that paper also wrote an article alongside Hannah Darlan speaking out against the study, which was an interesting turn of events. And both of those articles, the article I just mentioned, and the author's rebuttal are in the resource folder for this episode. So I do encourage you to listen to episode 161. In addition to this conversation, get yourself on the podcast mailing list at melaniethemidwife.com and you'll also get access to the resource folder which includes all the research papers that I used to make today's episode. And so now you can read them for yourself and make an informed decision about when and when you may not choose to engage the care of an obstetrician in your care.
[1:16:28] That has been today's episode of the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson, and I will see you in the next episode of the Great Birth Rebellion. 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.
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