A Better World in Birth?

Perth, Western Australia.  The Community Midwifery Program is rallying and lobbying to survive State Health Department cuts. This is despite the fact that World Health Organisation (WHO) guidelines recommend programs like these, and not the high-tech care provided in the “delivery suites” of the nation’s leading public or private hospitals. 

What is Community Midwifery?

Community midwifery operates on the principle that pregnancy and birth are a healthy and natural part of a woman’s life. It offers a pregnant woman continuous care from one midwife during pregnancy, birth and the post-natal period. The WHO states it clearly: primary care midwives are “the most appropriate and cost effective type of health care provider to be assigned to the care of women in normal pregnancy and birth, including the risk assessment and the recognition of complications.” WHO, 1999 Care in Normal Birth.

The reason? While doctors are experts in what to do when something goes wrong, midwives are experts in supporting women through the normal, natural progression of pregnancy and childbirth, including identification of when medical help is required. 

The Medical Model

Making an obstetrician, or even GP, the first port of call in a pregnancy, results in exorbitant over servicing at both public and private expense. Dr Marsden Wagner, former head of Maternal and Child Health of European at the WHO, points out that using an obstetrician to look after a healthy birth is like hiring a paediatrician to baby-sit a toddler.  

But the problem goes way beyond over servicing. Contrary to popular belief, when a pregnant woman takes the medical route, rather than reducing risks, the statistical outcome is the exact opposite. As Wagner explains, the choice to manage pregnancies and births with doctors, rather than midwives, imposes serious risks on the health and well being of both mother and child.   Wagner, Marsden “Fish Can’t See Water” in Birth International.

No Easy Way Out: Cascading interventions and costs

A paternalistic medical culture has convinced a large and rapidly growing number of women in Australia and the U.S. that they cannot withstand the pain of childbirth.  The magic bullet of epidural anaesthetic or Caesarean section is offered for a low-impact delivery.

Wagner describes what he refers to as an epidemic use of epidurals, leading to a cascade of interventions. The first intervention, such as induction of labour, tends to trigger a cascade of risky and costly medical interventions. “Normal Birth: What Are the Chances,” by Sally Tracy in Birth International.  Inducing labour increases the intensity of labour pains. This often leads to an epidural block. This in turn increases the likelihood of operative labour with forceps or vacuum extraction. Each procedure carries risks to the health of the mother and child. According to Wagner, invasive surgical procedures on the woman results in damage still evident six months postpartum, including 54% with perineal pain, 18% with urinary incontinence, 19% with bowel problems, 36% with haemorrhoids and 39% with sexual problems.

Is Caesarean surgery really Childbirth lite? 

If she has private health cover, the pregnant woman is likely to choose a private obstetrician and hospital which alone increases the likelihood of c-section to around 40%, compared to an already excessive Australian average of 21%.  It has been said that no obstetrician has ever been sued for doing a caesarean, only for not doing one.  The perception is that performing a caesarean section is the equivalent of a doctor taking maximum care.  Statistics in the US, Canada, Italy and the United Kingdom are similar. Yet according to the WHO, only 10% of women should require a c-section.

Caesarean sections are the only form of major surgery that a woman may contemplate (and a government will subsidise) with no clinical indications. Although it is sold as the easy form of childbirth, women are seldom given all the facts needed to make an informed decision.  Birthrites: Healing After Caesarean, Inc., a community organisation in Western Australia, provides extensive information about the risks of c-sections to the woman’s future fertility, her baby and herself.  One statistic from Birthrites gives the game away: c-section increases risk of maternal death by a factor of four. 

Shifting the blame 

Another problem with the current paradigm is one of responsibility.  The medical model of pre-natal care and childbirth coaxes women out of taking responsibility in an area, parenting, where their complete responsibility is imminent.  Having care of their children and themselves entrusted to the medical system, is it any wonder that women then look to that same system to take responsibility for any adverse events?  The “blame and claim” paradigm in obstetrics is a key factor in the medical indemnity crisis in Australia.

Pushing for Birth Reform

A decade ago, New Zealand reformed maternity care to promote midwifery.  This public health strategy has resulted in up to 80% of pregnant women receiving primary care from a midwife, with referrals to obstetricians only for medical complications.  Among many other things, this has resulted in a large reduction in the maternal mortality rate for Maori women, dropping to equal that of the European population.

The successful experience of maternity reform in New Zealand has been inspirational to Australian women looking to reverse dangerous trends.  In 2002, the Maternity Coalition published the National Maternity Action Plan. Based in Victoria, the NMAP advocates reforms in the maternal health system to enable all women to access publicly funded primary midwifery care as part of a national health strategy.   Rather than take further steps to implement this agenda, in late 2003 the state government of WA was said to be contemplating giving the Community Midwifery Program the axe to help ease its budget woes, sending the Maternity Coalition and its member organisations into action. 

Together with the Community Midwifery Program itself, Birthrites: Healing After Caesarean, Inc (http://www.birthrites.org/ )., Birthplace (http://barkingowl.com/~birthplace/ ) and the Family Nurturing Centre, the Maternity Coalition set about mobilising CMP consumers, midwives and other advocates for the program.  The Coalition gathered not only individually written testimonial support from over 60 program consumers and held a large rally, but also received political support from Labor, Liberal and Green Members of Parliament and the author of the State’s own obstetric report.

And you can see why.  Birth is possibly the most intimate and vulnerable experience a woman can have.  Under the prevalent system of medicalised birth, most women will give birth in strange place, under the scrutiny of strangers dressed in white surgical regalia, surrounded by noisy high-tech equipment and subject to much higher risks than necessary. 

Women have to re-educate ourselves in the area of childbirth, just as we have had to do in so many other aspects of our lives. Standing on the shoulders of the Boston Women’s Health Collective’s Our Bodies Ourselves (http://www.ourbodiesourselves.org/ )and decades of pioneering work in women’s health, we have become better-informed consumers and are making better choices about our health care. Only at the time of bringing a new child into the world is the trend in the other direction, with most women blindly handing over all decisions to the doctors. 

What if the main thing a healthy pregnant women needs to do to ensure a healthy birth is to experience the pain of labour, with the continuous and expert support of a midwife she knows and trusts? 

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Amy Bachrach is a recovering New Yorker living in Perth, Western Australia where she is an itinerant social change organiser.  She is co-author of Making News, a media primer for community services sector, and editor of the Not-For-Profit Webliography: a Resource  Book of Selected Websites for the Community Services Sector . She currently works for the Western Australia Council of Social Service www.wacoss.org.au , and has been organiser of EMILY’s List www.emilyslist.org.au in Western Australia.   She lives with her husband, Simon Cox, and their 2-1/2 year old daughter Abby, whom she birthed with the care of her primary midwife at the Family Birth Centre in Subiaco.

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