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Choice in Childbirth: a public policy failure
Exhortations last year by the treasurer, Peter Costello, that patriotic young Australians should go forth and multiply, caused more than a few indulgent chuckles from the assembled media. Many of those being urged to have more children were probably less amused as they contemplated the hurdles they confront in taking his advice.
I’m pretty confident the Treasurer had not given any thought to the fact that many young people delay having children or have fewer children because they do not have secure employment or affordable childcare. I’m willing to bet that he is not aware that there is virtually no choice for couples about where and how they have their babies, despite the fact that the rhetoric of choice peppers every second utterance by Coalition politicians.
Restricted funding and waiting lists for home births and home-like birthing suites mean that many low-risk mothers have no choice but to deliver in hospital delivery rooms. Many are simply not aware that there are alternatives to hospital birth. Others are fearful that they will not cope, that the pain will be unbearable.
Women are bombarded with messages that undermine their confidence in their own bodies’ capacity to give birth successfully, and which amplify their fear that they will not be able to exercise control over their birth experience.
Many women come to believe that birth is invariably safest in a hospital with an obstetrician attending or "managing" birth. And some doctors reinforce this view, threatening dire consequences to those who request more control and less intervention. An Australian Professor of Obstetrics put it crudely: "If women want to return to nature, then let these same women be prepared to take what nature dishes out."
The idea that, in general, childbirth can be viewed as a normal process in which the attendant, usually a midwife, simply assists in a healthy, routine progression is not given as much credence in public policy as it should, given the evidence. World Health Organisation spokesman, Marsden Wagner argued that:
Unlike in New Zealand and many parts of Europe, midwife-led care with appropriate specialist medical back-up is a rarity in Australia and only 2.4% of births take place at home or in home-like birthing suites.
Caesarean section rates in Australia have been steadily increasing from 19% in 1993 to 27% in 2002. The rate has reached a staggering 35% among private patients. These elevated rates do not appear to reflect the risk profile of the women giving birth, since the private patients are generally healthier and fitter, at lower risk, although somewhat older, than public patients.
Any reasonable analysis of the research literature on these trends makes it clear that increasing intervention does not produce better outcomes for mothers and babies. Indeed, there may be adverse consequences when such procedures are used unnecessarily.
In the developed world, it is countries which have the lowest rates of intervention and widespread use of midwife-led care which have the lowest rates of infant and maternal death, illness and injury.
Responsible obstetricians regard caesarean sections in uncomplicated deliveries as unjustifiable because, although caesarean section is today a relatively safe procedure, birth by caesarean section has been shown to be up to five times more hazardous for comparable mothers than vaginal birth. Keeping the caesarean birth rate as low as possible is therefore in everybody’s interests.
The Cochrane collaboration, which is the gold standard for assessing the benefits and risks of medical treatments, has concluded that “home birth offers a safe and acceptable alternative to hospital confinement for selected pregnant women and reduces the incidence of medical interventions”. A further review found that home-like birth settings for birthing mothers resulted in lower rates of analgesia, instrument deliveries and caesarean section than conventional settings and resulted in better experiences for the mothers without increasing the risks.
When continuous care is provided by midwives – as opposed to a combination of physicians and midwives – the Cochrane review also found that women were more likely to attend antenatal classes, less likely to be admitted to hospital during pregnancy, needed less pain relief in labour and had babies who were less likely to require resuscitation.
Most importantly, the babies born to these mothers were just as healthy and no more likely to die in childbirth and their mothers had more positive attitudes to the care they received.
Long term illness after childbirth while relatively rare, can be substantial, particularly following instrumental and caesarean deliveries. Specific concerns relate to painful intercourse, urinary and anal incontinence and depression.
No one would argue that specialist obstetric care is not sometimes needed, but it is increasingly obvious that intervention rates are now far too high for low-risk births. The result is a diminished experience for the mother and father of what should be a profoundly life-affirming event, increased risk of problems after birth and a great cost to the taxpayer.
One study has found that the average uncomplicated vaginal birth costs 68% less in the home than in the hospital. From the point of view of the policy maker, you get a better outcome, less intervention (without jeopardising the safety of the mother and infant), you provide what many parents want - a sympathetic environment with continuous care - and you can do it with a lower burden to the tax payer.
Childbirth is one of life’s major events, sometimes complicated, but mostly a natural process involving intense emotions and physical experiences; an event which profoundly changes people’s lives, and which can, and should be, very fulfilling for both mothers and fathers. It is the responsibility of all those involved in the provision of care – including Treasurers – to make sure that is.