Episode 218 - The Cascade of Intervention
[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. I'm your host, Dr. Melanie Jackson, and today I'm talking about a concept called the cascade of intervention. It's a concept that has previously, I believe, been hard to prove that it actually exists. I do believe that the cascade of intervention was a theory based on midwives and clinicians' experiences, but now I do believe that we've been able to scientifically map and track and prove, that a cascade of interventions exists.
[1:03] This episode has been generously sponsored by Poppy Child, who's a childbirth educator, doula, and creator of the birth box and the oxytocin bubble. Both of these things are strategic tools used to help you get ready for labor and birth. Historically, Poppy has offered Great Birth Rebellion listeners 25% off the birth box. And now, Poppy is also offering the oxytocin bubble, which is included in the birth box. But she's offering the oxytocin bubble as a standalone offer for 25% off for Great Birth Rebellion listeners. Now the birth box gives tools to help you navigate labor and birth and the oxytocin bubble is a soundtrack that accompanies those tools to help you sink into a calm and gentle space as you navigate labor and birth. If you want to access your 25% off offer check in the show notes below and you'll see the link. The terminology of a cascade of intervention, it's been knocking around for a long time. I remember reading texts before I was even a midwife, before I was a nurse, before I was a naturopath, actually, reading about this idea of the cascade of interventions. And some of the literature that I was reading was written in the 60s and 70s. So this is not a new idea to be saying that one intervention leads to another intervention. We call that the cascade of interventions.
[2:29] I don't know who coined the term. It's not new, but it is part of the common vernacular around birth now.
[2:36] And particularly around the medicalised practices of high intervention births, one of the consequences of a high intervention birth is that you can trigger the cascade of interventions, which means that one intervention leads into the next, to the next, to the next. So the terminology of the cascade of intervention, it's a descriptive way of explaining what can happen when you interfere with birth physiology. And I'll be talking mostly around birth physiology in this episode, but the cascade of intervention can be applied. It can start during pregnancy with excessive and unnecessary screening tools, for example, that then lead to the next thing and the next thing and the next thing. But today I'll use more birth examples of the cascade.
[3:27] And as always, in each episode of the Great Birth Rebellion podcast, I use current academic research so that each episode is defensible and factual and not just a pile of stuff that I reckon. So when you hear me talk about the cascade of intervention, I can assure you I have not plucked the information out of my imagination, out of my echo chamber that I'm in. I've read research. In fact, it's all listed in the resource folder for the Great Birth Rebellion podcast for this episode. So if you are part of the mailing list at melaniethemidwife.com, you'll be getting an email every Monday updating you on all of the workings of what happens at Melanie the Midwife, the work that I do.
[4:14] And part of that is the link to the podcast resource folder, which contains the research behind every single podcast episode that I put out. So if you want to have a look at the research papers that I'm talking about today and read them in detail I do my absolute best to make sure they are full text if they're freely available and so you can read them too.
[4:35] All you need to do is join the podcast mailing list at MelodyTheMidwife.com. It's super easy. I'll put the link in the show notes for you. All right, let's get started. The cascade of intervention.
[4:46] It's specifically associated with the medicalization of childbirth. And for that reason, it can be really easy to slip into conversations about the medicalization or the over-medicalization of childbirth in today's society. But I am going to try and sort of leave that over there and focus on the cascade of intervention.
[5:07] So firstly, I will define the cascade of intervention and I've just launched in and just started talking about it as if we all know what I'm talking about.
[5:15] But I want to also just comment on a few of the nuances around the cascade of intervention. So let's define what is the cascade of intervention. And the cascade describes the need for more intervention in order to remedy the impact of the previous intervention. So that's a nutshell and I'll say that again the cascade of intervention describes the need it's the terminology that we use to describe the circumstance, where you need more intervention to remedy the impact of the previous intervention that you had and if we backtrack a little bit and describe what an intervention is to start with because I just really want to focus on the fact that.
[6:01] Also not all interventions are bad. I know that some of you will be listening to this and thinking, oh gosh, she's anti-intervention. She's anti-medical management of birth. I'm not. I'm anti-over-medicalizing birth and I'm anti-unnecessary interventions, but I'm not, hear me again, not anti-medicine, not anti-intervention. There is a place for those, but it's not at every birth. And the reason why I think it's not at every birth is that the cascade of intervention exists. So if you're delivering one unnecessary intervention, you have to expect that it's going to lead to another unnecessary intervention because we made it necessary by giving the first unnecessary intervention. So backtrack a little bit.
[6:50] Because I want to focus on the fact that, again, not all interventions are bad, but we have to acknowledge that they are not all good either. Because some people believe that everything that you do to intervene in labour and birth makes it better and safer and more successful. And that without intervention, birth could not possibly unfold safely and without event if some kind of expert or medical person is in the room. We forget to tell women that interventions could possibly, and we've got academic research to show this, that interventions.
[7:28] Could introduce more risk or more danger into a birth and increase the risk of your birth where that risk didn't exist in the first place. So we've got to remember that while yes, interventions can create positive outcomes, change things from the worst to the better, but they can also change things that were going just fine and make them more dangerous than they needed to be. So that's what the cascade of intervention is. It's acknowledging that while some interventions can improve birth outcomes, we have to acknowledge that they can also make outcomes worse for women and babies as well. And this is why we have to be so careful when we're selecting, recommending and deciding on interventions is understanding there's both an intended and unintended consequence of offering or using an intervention during labour and birth. Every intervention has both an intended and unintended consequence. And the cascade of intervention describes what happens when the unintended consequences start to stack up and then more and more and more interventions are needed in order to deal with the unintended consequences or the side effects of the previous intervention. It sets off a cascade. It's like a set of dominoes. When you flick one over, the rest fall. And so if we're offering unnecessary interventions, we may also be inadvertently or knowingly.
[8:54] Offering a chain of interventions that are going to follow. But on the flip side, there could be a positive consequence to the interventions that actually resolve in a positive the expected or the hoped for outcomes. I'm not saying don't use interventions. I'm saying use them selectively for when they're actually clinically indicated and necessary so that we can fully benefit from the, positive things and the potential life-saving elements of interventions and reduce the possibility that we're going to introduce new risks and new complications to the birth process when they weren't there before. And I'll say it again, there is no doubt that some interventions are life-saving and medically necessary. And in these circumstances, the possible undesirable outcomes of an intervention are acceptable because the necessity of the outcome is clearly visible. We can clearly see that unless we do something, there could be a way worse outcome than if we don't do something. But today, I'm cautioning against routine interventions that don't have a clear clinical indication or medical reason. And I'm cautioning against these because all interventions have both desirable and undesirable outcomes. So we have to be selective when agreeing to interventions so that at each decision point.
[10:14] The benefits of an intervention outweigh the risks of that intervention. And deciding which ones are beneficial to you and which ones represent too much risk is up to you to decide in conversation with your care providers. The decision about what feels the safer or more risky option is something for you to decide because safety and risk is subjective. It's not a black and white conversation to talk about what is safe and what is risky. And so this conversation is nuanced. It's not for me to decide. It's also not for your care provider to decide. They can give you information and you can work together to make decisions. But ultimately, you, the birthing woman, are the one who decides which risks you're willing to take for which potential outcomes that you're willing to accept.
[11:06] So what I'm communicating today as we talk about the cascade of interventions, is that interventions don't just provide a linear, like a straight line trajectory, of if I do this, then I get this outcome. It's more like a spiral that goes here, there and everywhere. And eventually you will end up at your end point of birth. But in terms of being able to predict the outcome of a particular intervention or not it's not clear cut and it's not for sure there are a lot of uncertainties when you start to use interventions as to what impact they'll have so.
[11:47] We need to be thinking about this as a more gray conversation than a black and white one, and sometimes you will choose an intervention and it works exactly as intended and there's no side effects and the outcomes are largely positive and sometimes it doesn't do any of what you expected it to do and it only gives you more problems and you need to progress through to other interventions. So this is what we're grappling with because I don't want people to hear me saying that all interventions are bad and that you shouldn't have any interventions because they all lead to a cascade because that's not true. I've seen interventions work beautifully where things have become pathological and it's clear that we need to do something. And I've seen them work really, really well. I've also seen them completely fail and we've need to abandon the plan and move on to something else. But we can't predict this every single time. So I'm not saying no interventions. I'm saying let's exercise caution and use some clinical reasoning to decide which ones are necessary and wholly more beneficial and stop using them routinely when there's not a clear clinical benefit. That's if I'm thinking of it in a nutshell.
[13:01] So what I've already explained is what the cascade of intervention is. I've also explained that there are two types of interventions, those that are clinically and medically indicated, the ones that women sort of describe as needing the necessary interventions. And then there's the category of the routine interventions that don't have a clear clinical indication and I'll suggest also don't have a clear research basis to support their ongoing use. So a few of the routine interventions that I can think of that don't have a scientific backing, they're not based in evidence, they are routine and they're often done without clinical indication.
[13:48] If you imagine the moment that you walk into a hospital facility for example, Often, not always, women will be offered a vaginal examination to discover how dilated their cervix is. This is not an evidence-based intervention at all. In fact, we've got evidence to support the fact that it does not improve outcomes to be offering women routine vaginal examinations. This is purely based on hospital policy and protocol.
[14:18] And the next one is admission CTGs or any, type of continuous monitoring for women who don't have a clear clinical or academic reason to be having ongoing CTG monitoring. These are two routine things that are done. Most women will get these and they don't have any evidence to back them. So these are the things that we know do have a cascade that follow them. So let's talk about medically indicated interventions versus non-medically indicated interventions. So women will call them necessary or unnecessary ones. And I've quoted, there's a obstetrician who is the president of FIGO, which is the International Federation of Obstetricians. I was at one of his talks in Portugal and I agree with him when he says this. And I heard him say live in his talk, he said, Every intervention must have a clinical indication, and that indication must be evidence-based. Otherwise, it shouldn't be done.
[15:23] And this is the same in all fields of medicine. You would never give someone a medical procedure if it didn't need to be done, if there was no clinical indication. It shouldn't be any different in labour and birth. And this is the president of the International Federation of Obstetricians. And I have to say in an age of over medicalization of childbirth I agree with him on this statement and I'm so grateful that he said it and not me and I'm able to just reiterate his words.
[15:56] Medical procedures and interventions can either have a positive effect and result in the correction of the course of labor and birth if it's gone wrong, or they could be counterproductive and actually cause pathology in the process. For this reason, we have to be selective and we have to be interested in the evidence behind each intervention that we're offering. Does it actually help? Is it proven to have positive outcomes for women and their babies? And if it's not, why are we doing them in the first place? These are the questions we need to be asking because they can be counterproductive. We can be causing problems by the routine interventions that we're offering to women and we have to be responsible to that.
[16:40] All right, let's have a little conversation about unnecessary interventions. And these are the ones that upset women the most because often they'll look back at their birth process and realize there were things that they had that they didn't need. And then they start to question as to whether or not having those things are what caused if issues develop through their labor and birth. These unnecessary interventions that can't properly be explained or justified are the ones that are most upsetting to women.
[17:08] And these unnecessary interventions or routine interventions, they're actually embedded into the usual practice of most clinicians. And a lot of routine interventions are embedded into hospital or facility policies. Even if you're at a birth center or even if you're planning a home birth, there are some embedded processes that your care provider is going to go through in order to provide you with care, some of those could just be automatic, based on policy, based on the workplace culture, based on what that clinician just always does. And if you don't question them and ask them, why, why do I need this? Is this something that's actually going to benefit me? They may just go about their routine and we can forget to sort of consider, oh, do I even really need to do this? Is there a clinical reason for doing this? And I call, you know, it's a bit tongue in cheek, But routine interventions, I feel it's a little bit like birth by numbers, you know, like when you do paint by numbers. And it's sort of like, if you want to get this picture, you just...
[18:16] Green here, here and here and then you put red here, here and here and if you just follow the steps, the paint by numbers steps, you'll come out at the end with some kind of a picture and I feel like routine interventions are a little bit like that. It's birth by numbers so that when you go in to get care or you know you're getting care from your care provider, they have this sort of rote mental checklist in their head which is usually based again off their own usual ways of working which could be fueled by their workplace policies and their usual ward processes. There's a little bit of a cultural expectation for a lot of clinicians about how they are supposed to behave when a woman comes in. There's an admissions process for example and everyone's expecting that you will follow the admissions process. You've got to remember that these processes are set up for the functioning of the system and of the institution, it's a mental checklist for your care provider, but you don't necessarily, as the woman, as the labouring and birthing woman, you're not obligated to follow these in the same way that your care provider might be.
[19:26] And so an example of this is the admissions process, for example. There's probably an admissions form and you've walked in and they need to find you a room, check the baby's heart rate. Maybe they're going to use a CTG or not. They will offer you a vaginal examination because that's part of deciding whether or not you can be admitted to the ward. Because certainly if your cervix is not performing in the way that's expected by that facility, You may not even be admitted to the ward as part of their policy. There will be a tick list of things either internally in their head or literally externally on some kind of admission sheet. So it's birth by numbers. It's a little bit of a, there's a few rote processes that are involved. And these would be considered routine interventions, the ones that are embedded into the processes. And I have to say, I'm not, a lot of people are like, oh, you're anti-hospital, or you're anti-hospital midwives. Again, I'm not. I'm just commentating on how I see it and what the evidence says about it. But even as a private midwife, you know, as I reflect on my personal practice, I have routines as well that I use, you know, to not forget anything, to not, to, you know, to tick off my mental checklist. So when I arrive to a home, my usual process is to bring all of my equipment all in in one go.
[20:52] Before I even go and set it up, I go and I engage with the woman, check where she is, get a little bit of vibe of what's happening. Then the next thing I really like to do is listen to the baby's heartbeat.
[21:06] Does she need it? I don't know. That's just what I normally do. Does she even want it? I will ask her, is it okay if I listen to your baby's heartbeat? But if she said, are you worried about my baby? I say, well, I mean, I'm not worried at the moment, but I just routinely check the baby's heartbeat when I come in. It's part of my process. And so we all have, all clinicians will have a process. The important thing is, is that you explain it to the woman, give a justification as to why you think it should be done, and maybe if there is actually a clinical indication, and then it's up to the woman to decide if she's willing to accept that. She might want that information too. Most of the time my clients are really happy for me to have a listen to their baby's heartbeat and maybe in their own mind they're thinking, gosh, I wonder how the baby's going. It might be nice to listen to the baby's heartbeat. And again, all of these things I will talk to my clients about before even getting to the birth. So I talk to them about my routine processes for when I arrive at their birth. Once I've done a quick check over the woman, made sure she's comfortable, that the birth pool water is warm, that her TENS machine is applied appropriately, that her support people are feeling comfortable, then I go out and I spend some time setting up all my birth gear and checking that everything's in place, making sure my documentation.
[22:29] Is up to date. And all, you know, we have internal things that we do. We just have to be careful that they're not centered around non-evidence-based interventions so that we don't accidentally trigger off the cascade of intervention or be providing clinical care that's not evidence-based. Okay, so now we know what the cascade of intervention is. We know that there are such things as necessary and unnecessary interventions and that usually the routine ones are considered the unnecessary ones because they don't necessarily have a clear clinical indication, or often not even a scientific evidence-based reason to be doing them.
[23:07] So this makes it really hard for women because now women have to decide which interventions are medically or clinically necessary, because now they know because they're listening, you women are listening, you know that the cascade of intervention exists. And I'll explain some examples later. And now you know that we have to be cautious about which interventions we'll accept and which interventions will decline. So how do you work out which ones are routine and not necessarily clinically indicated, and which ones are medically necessary and the only real way you can know this in your own personal circumstance is to ask specific questions of your care providers so that in your mind you are certain that the interventions that you agreed to were the ones that you believed you absolutely needed.
[24:04] But you can't know unless you ask questions so, if you're offered an intervention or you're offered a screening test like a vaginal examination or an ultrasound that you didn't really think was necessary or do I what do I need this for start asking questions what is this for, and they might say oh we want to check on the heartbeat of your baby, are you concerned for my baby is there any reason why you would think that my baby is not well no, this is just a great way to get a baseline reading this is what they'll say about ctgs for example we just need a baseline reading and what they're saying is is we need to be able to prove that when you arrived your baby was well and the way that we prove that as a hospital is to have a printed out ctg reading at the very beginning of your care it doesn't necessarily mean that you need it it means they needed, but if you are a low-risk woman, that you're not having an induction.
[25:07] And there's no concerns for the well-being of your baby, why are you being offered continuous CTG monitoring? So ask, what is this for? And keep asking questions until you feel absolutely convinced with the information that they're giving you that you need this, that this is important for you and your baby medically. You can ask questions like, if I don't have this, is it likely to result in increased danger to myself or my baby? You could ask questions like, is this currently an emergency? Am I in an emergency? You could ask straight up, is this medically necessary right now or is this just part of routine care? Is this what everybody gets? And so you can start asking questions, whatever you need to know in order to make a decision of yes or no or not right now.
[26:02] And there is a little bit of a framework for if you've if you like acronyms the BRAINS acronym is a really common one that, midwives and people in maternity care use to as you try and make decisions about your birth, so you can think the BRAINS acronym is B for benefits what are the good things or positive outcomes that could happen if I accept this intervention? Because there might be a stack of benefits and very few negatives involved in the intervention that they're offering you. But your care provider needs to tell you both the benefits, that's B, and the R of brains, the risks. What are the risks? What are the downsides or the unintended consequences of accepting this intervention? What are the bad points, the dangerous possibilities or the side effects if I accept this what bad thing could happen, and then you balance the benefits against the risks it as you ask questions it will become incredibly clear to you if you're in an emergency or not and if the benefits have clearly outweighed the risks or not.
[27:18] The next thing you can do is ask the A question, B-R-A for brains, the alternatives. What are the other options? Could I wait a little bit longer? Is there another way that this could be done?
[27:32] Is there another time this could be done? Could it be done in this location versus this location? What other things are on the menu is what you're asking. Because often you'll be offered an intervention that the clinician believes is the one that you need or the one that they want to deliver to you. But there's usually a full menu of options that have not been presented to you. And so you may need to ask for the full menu. What are the alternatives? If I don't do this, what is another option? I did it recently. I was in hospital with appendicitis and the surgeon came to me and he said, you've got appendicitis. We think you need to have surgery to have this removed.
[28:14] And I said, let's say hypothetically that I decided not to have my appendix removed. What else would be done for me? And that was really, really helpful. And I actually took a lot of notes away from these types of conversations that I was having, even as I was advocating for myself. And he said, look, for some people, they just have an inflamed or infected appendix in which case antibiotics or anti-inflammatories could work he said however yours has an actual blockage it's a physical blockage and for this one antibiotics and anti-inflammatories aren't going to work if you decline surgery, my prediction is is that your appendicitis will get worse and not better you'll be in hospital for longer and the worst case scenarios it could burst and you're going to need surgery anyway so his suggestion was surgery before things get worse and so when i weighed up the benefits of keeping my appendix versus the risks.
[29:15] Of the appendix surgery and he presented to me the alternatives and it became pretty obvious that not many alternatives existed for me but if I decided against the surgery I could have been putting myself at more risk than if I agreed to the surgery so these are the types of conversations that you can have just like we would have had them in other circumstances where we're caring for our health ask what are the benefits what are the risks what else could I possibly do.
[29:43] The next thing that we use when we're making decisions about what to do next is our intuition. It's not just information that we need.
[29:54] There's a combination of things that go together when you're making decisions about which interventions that you'll accept and which ones you won't. So even if you've heard the benefits and the risks and the alternatives, that's information. And when you have the conversation with your clinician, they're going to add some what we call clinical reasoning because your clinician, your care provider is an expert in something too. Just like you are an expert in your body and you could be an expert if you've had babies before, an expert in how your body works, they have an expertise around clinical reasoning as well. They have some insight into what could happen. They know about, you know, other cascades of interventions and possible outcomes for things. So this is a conversation we're talking about. We're combining clinical reasoning with information and then the BRAI of the brain's acronym is about your instinct and intuition. What is your gut telling you? Sometimes it's a really easy decision because you're looking at it going, yeah, absolutely. I absolutely think I need this even before I have all the information or even before you've even discussed alternatives sometimes your intuition is telling you exactly what to do.
[31:15] And sometimes all the information seems to line up but something doesn't feel right your intuition is giving you a ping it's telling you to pay attention and it's participating in the decision making process.
[31:29] The problem with this one is, with instinct and intuition, is that for so long we've been told that information and knowledge and expertise is superior to intuition as a way of knowing. But can I just say they are on an equal plane and they interplay when we're making decisions. They're not isolated. Not one is better than the other. But unfortunately, we live in a world that doesn't value the art of intuitive decision making. And so not everybody has been able to hone their skill or trust their intuition when making decisions. I'm not that person. I was raised to respect, honor, and understand my intuition. And I believe it's pretty sharp. So I'm very confident in using my intuition to make decisions and trust that it usually doesn't steer me wrong, especially when you combine it with information and consultation with other experts and clinical reasoning, your instinct and intuition is something that you should at least listen to, pay attention to. Whether or not you choose to trust it is a whole other thing, but allow it to come into the process of decision making.
[32:42] The next thing in the brain's acronym is the N, nothing. What happens if you wait or do nothing right now? So you might be offered something when you arrive what happens if I don't accept that, they might say well it's of absolutely no consequence whether you accept this or not nothing is going to change for you okay well that makes the decision a lot easier doesn't it but you might want to understand if I don't do this, what happens if I wait or do nothing right now you can ask that question.
[33:18] Now, if you're not satisfied after this full brain experience and process, the final letter in the acronym is S. You can get a second opinion. You can ask another expert or another person for advice. You could seek out the information from the other support people around you. If you've got some wise people in your circle and you trust them and you want to garner some information from them, And this second opinion piece really can come in if you have a little bit of distrust for the person that you're having this conversation with. Sometimes you're in a care situation where you're only just meeting this brand new person who's going to be helping you make big decisions about your labor and birth. And maybe straight off the bat, either by their demeanor or the way they talk, or it could be anything, you just feel like you don't trust them. Maybe they said an unkind word. Maybe they were hurried. I don't who knows but something triggered off as I don't really trust this person I don't feel respected by this person and I want a second opinion so that's okay too, the thing is with interventions usually you can make decisions slowly you don't have to make them quickly, if you're in an emergency situation it becomes pretty clear that you need to make decisions quickly but most routine interventions can be delayed and you've got plenty of time to decide.
[34:46] So just remind yourself I can give myself space to decide and make decisions about interventions because interventions are powerful they have the power to correct a pathology and bring you back on course and then they have the power to spin you completely off course and cause a cascade of interventions that didn't need to happen. So this is just your reminder to think very carefully about which interventions are necessary and unnecessary to you because they're all powerful and they're all capable of both good and evil. I'm not going to say evil, but you know, there is this risk and benefits to weigh up.
[35:28] Now there are two seemingly innocuous interventions that are used so frequently during birth and labor care that I do believe that almost every woman is exposed to these. And we've got podcast episodes on both of these and I'll tag them in the show notes, but I want to just...
[35:46] Note some things about vaginal examinations and the use of routine CTGs or continuous fetal monitoring with where you're strapped to the fetal monitoring machine. Again, we've got dedicated episodes to these so that you can fully understand the research behind them and both the positive and negative consequences of these. But these are some of the interventions that you'll be exposed to routinely that don't necessarily have a scientific or evidence basis behind them. Whereas people will say, oh, we absolutely need these. We need vaginal exams. We need CTGs. We need, but unfortunately, there's no scientific evidence to prove that the routine use of both of these things actually improve outcomes for women and their babies. But it's become embedded in the routine labor and birth procedures that are offered to women. And I'll give you a little example. So I'm a home birth midwife and I don't do routine CTGs. I don't have a CTG machine. And I also don't do routine vaginal examinations. They're not evidence-based. Women don't like them and they are an intervention. So I reserve them for times of actual clinical need.
[36:58] But in hospitals, you'll be offered these around every four hours routinely and more frequently if there's considered a clinical need for these, depending on your circumstances. But I was with a client a while ago she was having a very long labor it was her first baby.
[37:17] And when you don't use routine interventions, and again I'm working in the home birth setting where I'm really in I've only got one client with me and I don't have anything else to do all I do is watch and pay attention to what's happening for her and respond to her needs and provide her with midwifery care.
[37:37] And so you notice a lot about labor and birth and you can start to become acutely aware of, you know, where she's up to, I'm using inverted commas, where she's up to in labor and birth, in the progress of her labor and birth, without even having to put your hands on her. It's just about seeing and visualizing how the labor is progressing and using her behaviors to understand where she might be up to. And so, you know, at this very long labor, we're getting to a point, I think it was about 30 odd hours in to the labor process. Again, if there's nothing wrong, there's no need to intervene or speed things up. But it became obvious to me that things weren't progressing. She seemed stuck. Things weren't moving forward. And I was having these thoughts. And of course, women are intuitive. She was also having these thoughts. And she said to me, do you know what? I think something doesn't quite feel right. I feel like something is stuck. I said, you know, I have to agree with you. This doesn't seem to be moving forward. Here are a few things we can do to try and understand this circumstance. There are some interventions I can offer you in this scenario where we both agree that maybe things aren't going well that we could do.
[38:58] And she had gotten to the point where she was feeling stuck and tired and she was done. She wanted something to be done to progress this thing forward. And we thought, right, we need to discover what's happening here. She said, either I want to go to the hospital or we can work out what's going on and see if we can fix it at home. So I did a vaginal examination. Again, it is an intervention. There are consequences to doing vaginal examinations. And if you want to know what they are, that both are positive and negative ones, have a listen to that vaginal examination episode that I'll tag in the show notes. For us, it was clear that there was a benefit to doing a vaginal examination. We both together wanted some information about what was going on and the vaginal examination could give us that. I was able to determine if her cervix was fully dilated. I was able to determine if her baby was moving down into her pelvis. And I was also able to understand what the position of the baby was. And that vaginal examination prepared, combined with me putting my hands on her belly and working out the position of her baby, we discovered that her baby was completely posterior. So it was facing the other way and it had become, it wasn't progressing beyond that point. She actually was fully dilated, but the baby was posterior.
[40:21] And so this intervention offered us an opportunity to understand what was going on and make a strategy going forward. So we did try some things at home that could have rotated the baby and again we were paying attention as to whether or not these worked and when it came to the point where we realized, we didn't think this was going to work to rotate the baby and the baby was clearly not moving down and coming out of her pelvis, she decided it's time to go to hospital because I'm done trying everything that we've been trying here.
[40:54] And so that was a beneficial intervention to help us understand what was going on and it helped us plan a strategy forward. She decided with all that information that it was time to go into hospital.
[41:06] Now, this is a woman who was planning a home birth and of course did not want to go to hospital but could see that the clinical scenario required it. She weighed up the risks and benefits and she decided she wanted to go into hospital. And when we arrived at hospital, again, an assessment was done. It was obvious what the problem was and the obstetrician offered her a manual rotation. So it was clear we needed to intervene into this process because the physiological process had stalled and the cause of that, which we discovered through the vaginal examination and the palpation was the posterior position baby. Some posterior babies can come out. Hers was not for whatever reason. The obstetrician offered her another intervention, which was a manual rotation. And this felt like the low-hanging fruit of possible interventions that could have been offered to her that day. Other obstetricians might have offered her a cesarean section or potentially a rotation with a vacuum cap or just a vacuum extraction or forceps extraction, or some kind of other rotation technique. This particular obstetrician offered manual rotation. Another intervention was done to offer pain relief into her vaginal area and vulva while the procedure was being done, all of which she happily accepted because she could see a clear benefit.
[42:30] The other thing that helped is that the obstetrician spoke to us about what would be done next if this didn't work. So what are the possibilities that this might not work? As it was, manual rotation was done, baby was rotated to an anterior position, which is the ideal one to push out your baby, and the baby came out. In this scenario, all of the interventions that this woman chose were carefully selected, They were clinically indicated and they were applied only when there was a clear need and she accepted them because there was a clear need, and they had a clear and overarching benefit compared to the scenario that she was in. This is an excellent use of intervention and this woman thoroughly believed that she needed them and was completely happy with the scenario that played out. Even though her original birth plan was not adhered to, she agreed that all of those interventions when necessary given her scenario and this is, when you start to acknowledge how powerful interventions are that they can have a cascade of negative outcomes or a cascade of positive outcomes you start to become a lot more careful with how you educate women and also for women how they choose and select them.
[43:48] Okay, so now I've spoken about the concept of necessary or indicated interventions versus unnecessary or not clinically indicated interventions, I want to further define and explain the cascade. But as I was researching this, it also occurred to me, that I'm looking at this whole idea of the cascade of intervention through incredibly privileged eyes and within a context that has high access to quality medical care so here in Australia where we are and perhaps where you are.
[44:22] In in most western countries we have the problem of too much intervention and too many resources and we squander them using them unnecessarily whereas other places in the world and sometimes in different pockets, in the same country there's a problem of not enough intervention and not enough resources to serve the needs of those women. Both extremes are problematic and it's two separate problems. It's too little too late and too much too soon is the problem. We've yet to find the middle ground of how much intervention is appropriate before it actually starts to become problematic. Some countries have a problem where they don't have enough access to interventions and this causes poor outcomes and ill health and the other extreme which is the problem that we're addressing today here on this episode of the cascade of intervention, is the abundance extreme where we use interventions simply because we have them without always considering if they're absolutely necessary we're operating out of a situation of abundance.
[45:32] The question is, is all of this intervention that we're using actually counterintuitive and creating harm? Because a lot of the arguments, I guess, for interventions are people say, well, if it weren't for all these interventions, the women and the babies would have poor outcomes and we'd have more maternal deaths and more neonatal deaths and more morbidities. And so what we have to ask the question is, are we now with these high level of interventions actually creating harm? And this is something that the academic literature has started to talk about. Is the moral and ethical grounds for the overuse of interventions is are we now actually not keeping women and babies safe? Are we inadvertently causing them more harm? And that's the discussion that we're going to have now.
[46:30] So, we know for certain, from research evidence, when we look at low intervention birth models, when you leave birth alone and only intervene when necessary, we know that the vast majority of births, even for women who have risk factors, we know that they will go mostly, for the most part, well, without interference. However, if we're truly to understand birth, we've got to understand that there are absolutely times when physiology does not work. And that we do need to intervene. Physiology does sometimes fail. That's a reality in labor and birth, and it's a reality in life in general. Our bodies are fallible. Sometimes our physiological processes don't work. It's a hallmark of humanness. It's a hallmark of our bodies. We are not perfect. It doesn't matter how much good stuff you input and every effort you do to stay well and healthy, sometimes it doesn't work and that's why we need interventions this is where their role is is when our physiology doesn't work and it turns into pathology and then we need interventions.
[47:43] But the trick is finding the balance because sometimes we're put in situations where the interventions and the way that women are being cared for is what's caused the problems, so the terminology the concept of the cascade of intervention reminds us that when you perform an intervention that you could alter the cause of labor and birth and if birth is unfolding physiologically and then an intervention is done as a routine thing it can throw off the delicate flow of labor and introduce pathology into the labor process when there wasn't currently pathology at all thereby kicking off the cascade of intervention and creating pathologies that now need to be solved with more interventions because of the first one and this is what often gets seen is that, we now need to do interventions as part of the cascade of intervention because we did the first unnecessary one that resulted in an undesirable outcome so the.
[48:47] The interventions start to become necessary, clinically necessary, but only because there was a medically induced reason for that. For example, we call this iatrogenic consequence, a medically caused consequence. We all know that there is iatrogenic causes for pathologies that now need interventions to solve them that wouldn't have existed had the first medical thing not happened.
[49:18] So the trick is don't intervene if it's all unfolding physiologically. If the woman and the baby are okay, leave it alone.
[49:27] Okay, now I want to give you some examples of the cascade of intervention. There are actually countless and one day I want to sit down at like some kind of magical.
[49:39] Retreat place and just map out there will be this huge wall of sticky notes just mapping out the cascade of intervention with research papers tacked onto each of them so you know you could scientifically prove this full cascade of intervention map I don't believe that that currently exists but it's on my to-do list, but I can take you on a little journey of some of the interventions that we do know seem to have a cascading event where one leads to the next, leads to the next, leads to the next. And.
[50:18] It used to be pretty tricky to link one intervention to the other. You actually, I do think you need to piece together multiple research papers. This is not sort of one body of work. But there are pockets of information that link certain interventions to other interventions. So I'll share some of the research of that with you today. But, you know, for some examples that I've seen is the very fact that your labor slows down when you move into hospital. A lot of people will say the first intervention that we do in labour and birth, is to leave our safe little space at home and travel into the hospital. And a lot of women comment that that journey, getting in the car, the lights, the interruptions, sometimes it's strangers, sometimes you're frightened. This interrupts the normal flow of labour and birth and sets off a little bit of a cascade of other things.
[51:13] Another thing is if someone breaks your waters, artificial rupture of membranes. I've seen this firsthand where a midwife, I believe, unnecessarily broke a woman's waters when she was eight or nine centimeters dilated. As a result of breaking those waters, the cord, the baby's cord prolapsed. And once it was recognized, it was clear that that woman now needed an emergency cesarean section. Cord prolapse is a medical emergency and it would not have happened in other circumstances had that midwife not broken the waters. This was a clear and immediate playing out of the cascade of intervention. These are just a few small examples.
[51:58] And these are examples of short-term cascade possibilities. But we also have to recognise that the cascade of intervention can have, there can be long cascades. For example, the Australian Institute of Health and Welfare report shows us that the most common reason for caesarean here in Australia is a history of having had a previous caesarean section. So 86% of mothers who had a cesarean section previously will have a second one. And mostly that's because a lot of the hospital services do not adequately facilitate vaginal birth after cesarean section. The prevailing messaging and psychology around VBAC is still that usually once a cesarean, always a cesarean. So 86% of women who've had previous cesarean section here in Australia will have another one for their next baby. Alternatively, if you flip that and look at the research on VBACs planned at home, the statistics are completely flipped. 86% of women who plan to have a vaginal birth after cesarean at home will have one, will succeed in having a vaginal birth.
[53:16] And so this is a long form cascade of intervention is that if you have one caesarean, down the line, you increase the chances that you are going to be offered another one. And there's a series of risks that starts to stack up the more caesareans that you have as well. Even after one caesarean, you increase the risk of placental implantation problems. You increase the risk of the woman having a uterine rupture. These are just a few of the cascade intervention consequences, the long-term ones, of having had an initial caesarean section. And of course, if you medically needed that caesarean section, of course, women are willing to accept the downstream risks. However, if you believe that that caesarean, the first one, was unnecessary and more and more of them are becoming unnecessary because our rates here in Australia are now over 40%. And 40% of women do not need cesarean sections. But the main reason for the growing reason for.
[54:24] Ongoing cesarean sections is that women have had a previous one. So now we have a long-term cascade problem where more and more and more women are requiring cesarean sections. And there was a great study done in 2021 by Fox et al, her crew, 2021. They looked at almost 100,000 women who gave birth over a three-year period in Queensland, here in Australia, in public hospitals. And they wanted to make a diagram, you know, that big mind map diagram that I was just talking about They wanted to make a chart to examine the factors that were contributing to the top two clinical conditions that led to cesarean section for women in Queensland. So here we are looking at even the pre-cascade situation that is leading women into cesarean sections. And the two things, the two main things that were leading to cesarean section, are firstly fetal heart rate anomalies, so abnormal fetal heart rates. And what they call, and in a circumstance of inadequate contractions. So again, I'm using inverted commas. So the two top reasons that they discovered for why women were given cesarean sections is a change or anomaly in the baby's heart rate, or it was deemed that the woman was having inadequate contractions to lead to labour and to actual birthing.
[55:49] So that usually means that either the woman's having a long labor or that the labor pattern isn't what they were predicting or expecting. And then also an abnormal CTG pattern, which we've already talked about. CTGs on the podcast, that's linked in the show notes. But the use of CTG, we know, we already know that the use of CTG increases interventions like cesarean sections, including cesarean sections, without positive impact on outcomes, actually. If you use CTGs, you increase the risk of having a cesarean section without actually improving the outcomes for either the baby and definitely not the mother because the cesarean section introduces more risk for the mother than if she'd had a vaginal birth.
[56:34] But those are the two major reasons that women were having cesarean. So among the sample of women who had a cesarean section, 41% of them had experienced a fetal heart rate anomaly. So abnormal fetal heart weight was the reason for 41% of women having cesarean sections. But then the study asked, but what was the reason for an abnormal fetal heart rate? Because 41% sounds really high. For me as a home birth midwife, it's incredibly rare during a physiological birth for the baby's heart rate to become unusual, where just suddenly and unexpectedly. That's so much so that they would need a cesarean section. Very, very unusual in physiological birth. So in this study, they asked, but why was 41% of the ceterians done for abnormal fetal heart rate? And they had a look at the sample of babies who had an abnormal fetal heart rate. And what they found is that 39% of those mothers had had their membranes ruptured artificially. So their waters were broken.
[57:41] Artificially by with a hook or by their midwife or doctor. So the 41% of women who had cesarean sections for fetal heart rate problems, 39% of them had had their waters broken artificially compared to the other group, that whose babies didn't have fetal heart rate problems. And then they found that 20% of the mothers who did not have their membranes ruptured, their babies ended up with fetal heart rate anomalies. So actually what they discovered is that if you break the baby's waters artificially, you almost double the chance that the baby is going to have heart rate issues.
[58:18] And then those heart rate anomalies, which then lead to the need for cesarean section. So now we can see a correlation from this study. There was a hundred thousand women in there. So now we can see a correlation between artificial rupture of membranes, leading to abnormal fetal heart rate, almost twice the chance of abnormal fetal heart rate in this study is from the babies who didn't have their waters broken, which then leads to cesarean section. This is what we're talking about with a cascade of intervention, a seemingly small, innocuous, and potentially routine practice of artificial rupture of membranes, then leading to the cascade, the undesirable effect of the abnormal fetal heart rate, which then needs to be medically managed and remedied by now a caesarean section. So that was the first tracking that they did with this data of 100,000 women.
[59:14] Then another thing they noticed was that among women who had oxytocin for induction or augmentation of labor with artificial oxytocin, so if you're in Australia, we call it syntocinon. If you're in the US, it's called pitocin, but it's artificial oxytocin.
[59:30] 32% of the women who were having inductions or augmentation with artificial oxytocin, their babies, 32%, experienced fetal heart rate changes, compared to 17% of babies whose mothers didn't have oxytocin. So again, when you use oxytocin, if you want to use this study as evidence, it doubled the chances of the baby having an abnormal fetal heart rate, which then required them to go on to a cesarean section. So now here, they've linked oxytocin or artificial oxytocin for induction or augmentation to abnormal fetal heart rates, which then requires a necessary cesarean section because the baby is in distress. So now that they've noticed a connection between those interventions and abnormal fetal heart rates, which led to these primary cesarean sections, and what we know is the main reason for a second caesarean section is the first caesarean section. So now we're getting a picture of what we're talking about with a cascade of interventions, is if we can stop that first unnecessary or non-indicated intervention, we could prevent the rest down the line. This is the cascade at play.
[1:00:46] Now, if they've been able to track that there is an increased risk of caesarean section and an increased risk of the causes of those caesarean sections, like artificially rupturing membranes and initiating artificial oxytocin. Then they also looked at epidurals in this study. This is done in 2021. Again, if you want to read this study, it's by Fox et al. From 2021, it's in the resource folder. You can have a look at it. You just got to join the mailing list and you get access to the whole thing.
[1:01:16] Now they've looked at epidurals. 52% of women with an epidural who had a cesarean section had their cesarean section because the baby's fetal heart rate was abnormal, compared to 38% of women who didn't have an epidural. So if you didn't have an epidural from this study, there was a 38% chance that your baby would have a fetal heart rate change requiring cesarean section. If you did have an epidural, that risk went up to 52%, that chance that your baby would have a heart rate anomaly requiring a cesarean section. So what this study is saying is that one of the main reasons for primary cesarean section is abnormal fetal heart rate and that the main causes of abnormal fetal heart rate are epidurals, artificial rupture membranes, and the use of artificial oxytocin. And then they looked at this sample of women who had inadequate, in inverted commas, inadequate contractions. So that was one thing that they looked at was abnormal fetal heart rate and requiring cesarean section. Now they're going to look at the group of women who had, quote unquote, inadequate contractions. And so then they looked at women who had epidurals versus women who did it. And 33% of women who had an epidural in this study were.
[1:02:39] Ended up having inadequate contractions as a result requiring cesarean section. When you compare that to 10% of women who didn't have an epidural. So if you don't, if you have an epidural, you're three times as likely to be exposed to the result of your contractions starting to die off and reduce, requiring the next intervention, and possibly leading to a cesarean section. So what they found was, is that epidurals seem to lead to inadequate contractions.
[1:03:13] So that was the Fox paper from 2021, if you're looking at the resource folder. Now, this other paper that I'm going to finish up on is from recently, a few weeks ago, in fact, early August, 2026. And it's called, Why are Cascade Birth Interventions Rising? And this paper looked at an Australian data set, but honestly, this study could have been none anywhere, they looked at an Australian data set of 1.3 million births. And the data was collected from births between 2004 and 2018. And the researchers in this paper, identified first a growing prevalence of the cascade of connected interventions which included induction of labor.
[1:04:01] And an epidural which led to either instrumental birth or cesarean birth. So this is somewhat connected to the FOX study, the 2021 study that found the connection between rupture of membranes, fetal heart rate changes and subsequent cesarean sections, and the risk that epidurals posed to the reduction in uterine contractions, which then lead to caesarean sections. So they made a few connections in their paper. This paper is looking at the interconnected interventions of induction of labor and epidural, which then either lead to instrumental birth or caesarean births.
[1:04:40] And the purpose of this paper was to try and determine why there was an increase in this cascade of birth interventions in particular. Why are more women being induced, more women using epidurals, which is then leading to either more use of instrumental births with vacuum or forceps or cesarean section births? And if you want to read this full paper, it's called Why Are Cascade Birth Interventions Rising? Very prestigious lineup of authors on this one. So I do feel as though it's a very trustworthy paper. And in fact, it's quite a word salad when you look at it, you've really got to read the details. of this particular paper. And so if that's not your strong suit, then I do hope that this podcast episode is helpful for you. But I do think this is a uniquely positioned paper to help explain why cascade birth interventions are rising. And I'll tell you the answer as we go.
[1:05:39] So to answer their question, in pursuit of the answer of the question, why are cascade birth interventions increasing? They found that the group of women who were experiencing the fastest growing rates of cascade interventions were not the women who had complications. And now this is the argument that a lot of people say, and people say it to me all the time when they comment on social media. Well, of course the interventions are increasing because women are getting sicker and further and older, and there's more confounding factors. They've got more risk factors. Therefore, we need to intervene more often to keep them safe because they are the problem. So this has been one of the arguments. The other argument is that women want more interventions. They are asking for interventions. They're asking for inductions. They're asking for cesarean sections. All right. So these are some of the background reasons what the medical profession and the maternity care profession is. Some, not all, are trying to say, well, we, of course, we're intervening more because more women need our interventions. So this study sought to find out, is that true? Is that the reason why? And if that's the reason why, maybe they do need more interventions, but let's have a look.
[1:06:51] So is the reason that we need to rescue more women from their sick, old, fat bodies? Probably not. But what these researchers found was that the rate of cascade interventions are increasing for both women who have risk factors. And they've got a very handy graph in there. They're increasing at a very similar rate for women who have low risk pregnancies, who don't have any risk factors. So what they discovered is that the increased use and application of interventions and then their subsequent cascade of consequences is not isolated to women who start their labour, unwell or who have risk factors or who are at high risk. It also is happening the similar increase when you look at the statistical increase the charts look almost identical if you compare the chart for women with risk factors to the women with no complicating factors they are each being exposed to an equal and similar rate of increase in cascade interventions. So in fact their risk status versus their exposure to these interventions is irrelevant. Each group was equally exposed to the increased use of intervention.
[1:08:12] And what they actually said was, is that the rise in cascade interventions is, and this is a direct quote, concentrated in low-risk Nully Paris women. So women who are having their first baby who have no risk factors are at the most risk of having high levels of intervention.
[1:08:33] So if you've not had a baby before and you are at low risk of complications, what this paper has shown is that you are becoming at increasing risk of the cascade of interventions more so than other groups. The growth is concentrated in low-risk women. So they concluded that there were large variations in the use of cascade of interventions from hospital to hospital and that each of the hospitals, so hospital level practice styles, inverted commas, so individual hospital level practice styles, are what is contributing to the increased intervention rates and not the compositional changes in the characteristics of women who are giving birth. What they said was they've been able to isolate the fact that it's not the change in the needs of women that's increasing interventions, it's individual hospital level practice styles. What they're saying is the environment that women go into is what is increasing the risk of them being exposed to increasing levels of intervention. What they were able to identify is that some hospitals didn't exhibit a trend of increasingly applying cascade interventions versus others. So they've actually been able to isolate that it's not the needs of the women and it's not all hospitals. It's isolated to specific hospitals. And I'll see you next time.
[1:10:01] So they showed in their study of 1.3 million women that it's not the women contributing to the increased use of cascade interventions, including inductions, epidurals, instrumental bursts and cesarean sections. Rather, it's individual hospital practice, individual hospital culture, and these tendencies account for the increase in the use of interventions over time.
[1:10:30] Now, this study is not the first to call out the very fact that the way that we've institutionalised birth is actually leading to the increased use of interventions. The World Health Organisation has also noticed the steady rise in birth interventions and how they've become a defining feature of modern maternity care. And the World Health Organisation has raised concerns, over the last 20 years in the application of a range of labour practices that are used to initiate, accelerate, terminate, regulate, or monitor the physiological process of labour and birth. And this study, the YR Cascade Birth Interventions Rising study, they found that part of the problem is why are these interventions rising, is that non-medically indicated interventions are increasingly being applied, to low-risk births and that there is a significant variation in hospital-level practice styles, which is what has contributed to this trend.
[1:11:34] These are not things that can be attributed to the women themselves. They found that the upward trend in interventions can be linked to care specifically given to low-risk women who haven't had babies before. And what they found that over, between 2004 and 2018, The rate of induction of labour for women having their first babies has risen from 28% to 46%. And the highest growth, the most exponential growth, is those early-term inductions for low-risk women between 37 and 38 weeks. They rose from 20% to 49%. That was the first category that rose. The second reason for induction that has risen over the last 20 years is the category of, and this is in inverted commas, induction for no medical reason. This was the fastest growing reason for an increase in induction of labor for low-risk women having their first babies.
[1:12:40] The number one reason that low-risk women having their first babies are being induced is for in the category of induction for no medical reason.
[1:12:51] So this study also found when they analysed the data for 1.3 million births, that only 26% of low-risk women who had an induction of labour combined with an epidural went on to have a normal vaginal birth. I'm going to say that again.
[1:13:09] Low-risk women having their first baby in this study of 1.3 million births.
[1:13:19] If they had an induction of labour combined with an epidural, only 26% of them went on to have a normal vaginal birth. So these researchers, based on their study, explained their answer as to why are cascade birth interventions rising, and they concluded that their findings, and this is a direct quote, that their findings support the view that it is practice styles shaped by institutional culture, care provider incentives and clinical norms that appear to be the key driver of increasing intervention rates. That's a direct quote. I didn't say that. The researchers said that. The reason interventions are increasing is because of institutional cultures and.
[1:14:10] Individual practice styles of clinicians, care provider incentives, and clinical norms, what we've just always done. The authors state that their study demonstrates that concerns over the decline in normal vaginal births, it's not simply about reducing cesarean births, but rather the decline in normal births is the full consequence of interventions that are designed to initiate and progress labour and birth, like inductions. So within a policy lens of improving health system performance, as well as a commitment to normal birth, the authors say that their results support initiatives that should be aimed to improve evidence-based use of all interventions, as well as properly informing women of both the risks and benefits. So they are calling for clear documentation of informed maternal consent around the discussions of interventions. And when you're giving informed consent, you have to cover both the benefits, the research, and the risks of everything that we've been offered. And their paper showed that there is increasingly non-evidence-based use of interventions. That's why we're using them so judiciously.
[1:15:33] And women aren't being properly informed of the consequences of that. So this paper asks that we improve initiatives around the use of evidence-based interventions and have an effective documentation and informed maternal consent process.
[1:15:51] And in this paper, they also identified that on an individual hospital level, that the rates of intervention were increasing disproportionately to the needs of the women. So the variation couldn't be explained by the case mix of the type of birthing woman who was there. So when they had a look at the needs of the women and the rates of increased interventions, they didn't actually match up. So using this paper, they've actually, this data, these researchers have been able to tease out and quash the argument that women are getting more interventions because they're older, sicker, fatter. That is the cat cry, is that women need more interventions. That's why they're getting them. What they're saying is no. The increase can be explained by individual hospital practices. And they explained that some hospitals had a practice style that was more aggressive, technologically intensive and invasive when they compared it to some of the other hospitals. And they said that in the case of maternity care, the more aggressive practice style is usually characterized by an increase or excessive use of birth interventions, specifically unnecessary birth interventions. And these unnecessary interventions, the amount of aggressively applied excessive use of interventions was a proxy for excessive use of cesarean section. So they found that they existed together.
[1:17:21] So this paper confirms what we probably already learnt from the research previously, including there's a place of birth study. It's a place of birth in England study. We also did it in Australia. And what they found is that some venues, depending on where you give birth, the venues lend themselves to either higher or lower levels of interventions. And that it's not usually the needs of the woman that drives these interventions, it's the philosophy and usual practice of that facility. So, for example, they found compared to home, birth center, hospital birth, public hospital, private hospital, your level of intervention continues to increase the deeper you go into this more aggressively medicalized model. And it's not necessarily related to the needs of the woman.
[1:18:13] And what the 2026 paper discovered and how they described some of these facilities as more aggressive and technologically intensive and invasive is if you want, a less technologically aggressive birth approach to be applied to your birth, what we know from the place of birth study in England and from this study as well, is that it's important to make decisions around the location that you choose you can choose a less interventionist model of care or less interventionist location like midwifery care and venues that have usually, and midwives who work in midwife-led units like birth centers or lower acuity hospitals or in a home birth setting and, there's less of a tendency to intervene because it's not part of the usual practice. So the venues with the lowest intervention rates are usually home births, followed by birth centres, then followed by public hospitals, and the highest rates of intervention are usually experienced in private hospitals. And again, I know people will be saying, oh, the rates of interventions are higher because the risks of the women in hospital settings are higher. But what this research paper showed the 2026 paper about why are cascade interventions increasing they answered this thought.
[1:19:36] Because when they tracked the increasing trend of interventions and they graphed it for high-risk women and then compared it to low-risk women the graph trend was the same the same increasing trend is happening for both high, and low-risk women and this indicated that it wasn't the increase in risk factors that was triggering the increase in interventions. Because if it was, there would be an upward trend in interventions for women with risk factors and no increase trend in interventions for women with no risk factors. So the fact that even women who have no medical indications, who go into their labour as a low risk woman, low risk of complications, they're being given interventions at the same increasing prevalence than higher risk women. And that indicates that the women's medical needs are not the driver and that it's more likely to be an institutional and practitioner behaviours that are increasing and causing these cascade interventions. And now that you know this, you as a woman can make choices to either opt in or opt out of services.
[1:20:49] That match your preference. You may have a preference for aggressively technocratic high intervention births. In that case, you need to choose a facility that allows for that, that lends itself to that, that sort of is the natural flow of that facility. But if you want to avoid all of that, if you want a low intervention birth, if you only want interventions that you believe are absolutely necessary and to reduce the number of interventions that you're going to get as routine, then you need to choose facilities that are characteristically, lowering interventions and more likely to be midwife-led. It's important to make choices about your care provider and birth location that match your own birth philosophy and intentions.
[1:21:37] In the Fox paper, the 2021 Fox paper, and then also commented on the 2026 paper, was the use of epidural as one of those cascade interventions. And if you want to avoid the cascade, of course, sometimes women need epidurals. But if you are keen to avoid the cascade that can occur with an epidural, you've got to have some other strategies around how you're going to navigate the pain and sensation of labor. And fortunately I've got something for you and it's super easy to access it's the guide to giving birth without pain medication and it's got a whole raft of tools and strategies that you can use if you want to avoid epidural for your labor and birth it's not enough to say don't use an epidural what you need is other things that you can put in place of the epidural so that you actually can deal with the contractions of labor and birth and that's what the guide is it's a collection of tools and strategies that I've seen work over 18 years. I've been a midwife for 18 years and I've been attending women who give birth at home. And those women don't have access to epidurals. They don't have access to any pain medications, yet they continue to use strategies and navigate their labor and birth without pain medication. I've put all of these strategies in the Guide to Giving Birth Without Pain Medication. It's for you and there's a whole section for your partner so that you're fully prepared to put alternative strategies in place if you're trying to avoid an epitril.
[1:23:06] That's today's episode of the Great Birth Rebellion podcast. If you want the guide to giving birth with pain medication, just check the link in the show notes below. If you want to have a look at all the research that I've used to create this episode, you'll also find that in the show notes below by joining the mailing list at melaniethemidwife.com. I'm Melanie Jackson, and I'll see you in the next episode of the Great Birth Rebellion podcast.
[1:23:30] To get access to the resources for each podcast episode, join the mailing list at melanethemidwife.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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©2026 Melanie The Midwife
