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The real safety issues in maternity care: a sneak preview

Maternity care provides a classic example of the pitfalls of a specialist-driven model of practice in health care. It results in more expensive and interventionist care, rather than a community-based approach which could also help ensure a more equitable distribution of services. It has led us to talk about obstetrics, which implies a focus on a particular professional group, rather than maternity care, which implies a broader focus on the woman’s and baby’s needs, both before and well after the birth.

Professor Lesley Barclay, director of the Northern Rivers University Department of Rural Health in NSW, is a leading proponent of the need to reorient maternity care around the needs of women and babies, and has plenty of first-hand experience of why this is particularly necessary for women living outside the major cities, especially Indigenous women from remote communities.

This coming Saturday, she will be speaking at the Australasian Medical Writers Association conference in Sydney.

Here is a sneak preview of her presentation:

“When women talk about what matters to them when it comes to childbirth, the issue they repeatedly mention is safety.

But their understanding of safety around childbirth is often quite different to how health systems and many professionals define it.

For women, a safe childbirth is not only about what occurs at the time of the birth. It also refers to longer-term issues, such as their social and emotional wellbeing in the weeks and month after the birth.

When women talk about safety, they are also thinking about the increased rates of depression and anxiety that manifest after operative birth or the consequences of wound infection on general health.

The Australian health system often makes it difficult for women to make wise choices around birth. Consider, for example, how the system defines childbearing as “obstetrics” and locates it physically and psychologically in acute care hospital services.

It is far more appropriate to speak of “maternity care”, which can be safely located in many locations.

For example, evidence shows for most women most of the time birth does not need to take place in hospital. Some women will only feel safe however, whether this is evidence-based or not, with specialist medical services and technology.

The term “maternity care” describes the range of services women need to enable them to safely and confidently ‘mother’. This incorporates their social and emotional needs. It puts them – rather than the professional or the service – at the core of the system.

Evidence shows maternity care can be provided by both midwives and obstetricians in public and private sector hospitals and can be safely provided at home.

Paradoxically, evidence also shows that safety from morbidity is less likely for Australia’s healthiest and wealthiest women cared for by private obstetricians in private hospitals. More recent epidemiological evidence shows as volumes of operative birth increases, deaths of mothers and infants are also increased by overuse of the very operation that was developed to save lives.

So where does choice fit in this repertoire of terms, locations, professionals, services and outcomes?

Safe birth should be the goal of choices offered to women and decisions taken by those who provide care for them.

Unfortunately, the choices some professionals offer or accept are self or income centered and ignore evidence. As a consequence of gender-located power historically, and a rapid increase in the numbers of more technically oriented professionals in recent decades, health services and costs do not reflect women’s needs or evidence.

The most important example of this is allowing caesarean birth to be a choice rather than only using this as the lifesaving emergency procedure it is.

Today, in many places around the world, including Australia, caesarean birth is rapidly becoming a life threatening procedure itself because of excessive use.

Epidemiological evidence from a number of countries, maternal death reviews and coroner’s reports now show the risks attached to using a major surgical procedure as a routine mode of birth.

Maternal mortality is between two and seven times higher for surgical than vaginal birth. One study of over one million women between 2001 and 2003 in Brazil found, compared to having a vaginal birth, women with CS were 3 times more likely to die in childbirth.

A large US study of 5 million births between 1998 and 2001 demonstrated that neonatal mortality for CS deliveries is nearly 3 times greater than for vaginal birth in women with no medical risk factors.

The physical, social and emotional morbidity attached to women who experience this mode of birth is not recognised therefore ignored within acute care hospitals but is evident in their homes and the community.

Research has identified that physical morbidity associated with CS is five to ten times higher than for women birthing vaginally. No less importantly there are also psychosocial consequences of surgical birth with women less satisfied, more concerned about the baby’s condition and fearful. Women delivering by CS report feeling less in control than women who have birthed vaginally.

Research also shows rates of post natal depression significantly different between women who birthed vaginally and the group of women who delivered either by planned or unplanned CS. There are also differences in parenting perceptions and behaviour between women delivering by CS and vaginally. Women who birth by CS evaluate their babies less favourably, are less likely to breastfeed and/or feed for a shorter duration.

Paradoxically, the choice to have a normal, safe, confidence affirming birth that is low cost and relieves pressure on hospitals is only available to a small minority of women.

This is not possible for Australia’s most vulnerable women and families, who, the evidence suggests, would benefit most. How many rural or remote living Aboriginal women can opt for a home birth attended by a skilful midwife?

Research associated with our NHMRC funded work in the Top End of the NT has shown that 1 in 10 remote living Aboriginal women in one large community avoid hospital services or skilled professionals because of the unacceptable risks to them of being evacuated from their community. One of the reasons they avoid large hospital birth is this takes them from families and other children for weeks at a time.

Other Australian women with more options are also taking this route, fed up with what they see as biased, self-interested advice and unacceptable risks of our current system.

To have real choices, one needs options and good information on which to base decisions. Better resourced women, with access to Internet searching, can chase evidence themselves, or question doctors, hospitals and midwives. They can try to weigh up the range of opinion they are likely to receive. It is hard to know at times where fact lies in the opinions you will generate through asking questions. H

However there are some ultimate arbiters beyond opinion. One of these is the impartial review of evidence provided by such as the Cochrane data base.

I saw to my great delight a writer (male and medically qualified) who also a Member of Parliament, recently quoting this source in a newspaper. His message, while aimed at indemnifying home birth midwives, was that home birth is safe.

He had gone to the Cochrane and reported back in his article that home birth is indeed safer at times than hospital birth when planned and supported by good hospital care for rare emergencies.

I wish the current president of the AMA, an erstwhile obstetrician, would be similarly correct with his claims that certainly are not recognisable as fact to those familiar with the evidence.

Choices for women are difficult when all they receive is highly partial and ill-informed opinion. Choices around birth are important or women will opt out of a system that does not meet their needs.

The Australian maternity system has been associated with increasing risks over recent years and is certainly much more expensive than it need be.

The Commonwealth aims to change this. Recent budget moves to allow midwives to claim for midwifery services and to increase choices for women will, evidence shows, reduce risks of physical and social morbidity. Location for birth similarly is a choice that women make that with good support systems will reduce cost, reduce morbidity and not increase deaths.

Should it be a matter of choice though for women to give birth via major abdominal surgery? Should we permit choice that means their babies avoid the process of vaginal birth that prepares them to live and breathe?  Should it be women’s or obstetrician’s choice that health pays or heavily subsidises the avoidable costs of unnecessary operations that prevent other necessary surgery being performed and add to waiting lists? I think not.

We need to recognise that operative birth is the option to use only when the risks associated with the alternative are unacceptable. This is not a matter of choice.”

Comments 7

  1. Doctor Whom says:

    I think Norman Swan or some one had a person from Cambridge? just today or on the weekend speaking about rates of caesars related to many women giving birth at a later age these days.

  2. Ian Haywood says:

    When I was an obstetric HMO, I remember several times being called by midwives to see a woman in early labour (progressing normally) who asked for LUSCS because they were scared of labour.
    I did my best to reassure them, talk about the benefits of VB, etc., usually not very effectively, being a bloke (and I assume the midwives had already tried), but in the final analysis I stood at the foot of the bed and said “No”. The author seems to suggest this is right, but I’m unsure how this form of medical paternalism differs from other forms that Crikey contributors wouldn’t approve of.

  3. Bogdanovist says:

    I don’t have nearly enough information about the subject matter to make an informed comment, but statements like this disturb me:

    “Research also shows rates of post natal depression significantly different between women who birthed vaginally and the group of women who delivered either by planned or unplanned CS. There are also differences in parenting perceptions and behaviour between women delivering by CS and vaginally. Women who birth by CS evaluate their babies less favourably, are less likely to breastfeed and/or feed for a shorter duration.”

    Stay after class and write out 100 times “correlation is not causation”. Much of the rest of the article sounds compelling, but given the above demonstration of how statistics have been mistreated, I’d want to carefully check the sources of the evidence being presented.

    The other thing that I think is counter-productive is insisting that this is a gender issue. It hardly encourages fathers to get deepy involved in the whole process when things are constantly phrased as “choices for women are….” etc. Why is it only women who “can chase evidence themselves, or question doctors, hospitals and midwives”? I’d hope that when and if my wife becomes pregnant I’d would be equally active in this information gathering and decision process. It’s a shame that the author, while clearly passionate about the issue, makes the assumption that my role is over once sperm has been provided.

  4. B'Jango says:

    In response to Ian Haywood, “No” is the responsible answer in this situation. Would a surgeon amputate a healthy limb or even perform any major surgery on a healthy person unnecessarily? Not all choices are equal and it is the health system who have failed women in leading them to think that they are.
    What is going on here in our maternity system? I am a midwifery student and have just finished working in an obstetric led delivery unit. This is normal, low risk care in a public hospital. I saw hardly any vaginal births, taken over by instrumentals and cesareans. These were not at the request of the women, nor midwives but the obstetric registrars who seem to be practicing emergency care on well women who are unlucky enough to be the recipients of interventionist, invasive treatment. Not even evidence based practice, the AMA have a lot to answer for if they think this is gold standard. Prof Lesley Barclay has won an Order of Australia award and served as a WHO advisor, lets take a little more notice.

  5. Croakey says:

    Discussion about choice is often framed as an individual issue in these discussions in a way that doesn’t take into account how the set up of the system can influence “choices”. For eg if there is no continuity of care – the woman sees different practitioners before, during and after the birth, then women in this situation may make different choices to those who’ve had the same practitioner/s providing advice and support through pregnancy, the delivery and in the postnatal period. So it’s not all about individual choice; it’s about whether the system supports and enables the choices that are most likely to be of benefit to the woman and her baby, whatever these may be.

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