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Choosing your model of care (& why you need to know this information first)

“Childbirth is absolutely a human rights issue. When you are making decisions about somebody's body, their personal autonomy, their right to decide the circumstances in which they live, breathe, and function, you have to abide by those fundamental human rights. And what we are seeing in pregnancy and childbirth is women all around the world are reporting that as soon as they become pregnant, there is a presumption that those rights don’t apply to them.”

– Bashi Hazard




Speaking directly to the Australian context, we have biasedly more access to some models of care than others. Not only in pregnancy, birth, and postpartum but within our healthcare system as a whole. Speaking directly to pregnancy, birth, and postpartum, the model of care you choose deeply influences the type of experience that is easily accessible to you.


I say 'easily', because as many would know if you have birthed or supported birth, there can often be a fight to be heard, seen, and held in this time depending on where you are birthing. As the trained psychology student I am, I have delved into research to provide numbers and statistics for those who relate most to this type of information. If that is not you, bypass the numbers but please see their place in mirroring the current culture we live in and the seriousness of understanding it all for your own journey.


**PSA: many who read this may have had a great, positive, and caring experience in public or private OB settings (I myself have supported many positive and empowering public hospital births). Please know I am not demonizing these models of care, but urging women and couples to consider the birth culture within Australia and how that translates to our models of care, care providers, and care provider beliefs around birth, to then understand how it directly impacts your experience.


What models of care do we have?

To keep it simple:


  • Public hospital maternity care

  • Shared care (often with a GP and the hospital)

  • Midwifery group practice/Caseload (MGP)

  • Private obstetric care (OB)

  • Private midwifery care


Read more information about each model (as well as some others that are a lot less common) here: Maternity models of care in Australia, 2023, Major model category definitions - Australian Institute of Health and Welfare (aihw.gov.au)


The availability of such models in 2023 goes:

  • 41% are within public hospital maternity care

  • 15% shared care

  • 14% MGP caseload care

  • 11% private OB care

  • With over one-third of models having no continuity of carer in any stage of the maternity period

  • 35% having continuity of carer for some part of the maternity period (only antenatal or postpartum) and

  • 29% having continuity of carer through the whole maternity period (highest numbers found in QLD, SA and ACT). This 29% includes OB care, private midwifery care, and MGP caseload care


Why does continuity of care matter?

Ongoing research has highlighted the importance of continuity of care not only for maternal and baby health outcomes but the satisfaction mothers and fathers/partners are experiencing in their pregnancy, birth and postpartum care. Research aside, it also just makes so much sense that those we know we are more comfortable with during such a vulnerable and intimate life event.


A Cochrane review of 26 studies from 17 countries involving more than 15000 women showed that women who received continuous support during childbirth are:

  • more likely to give birth spontaneously (vaginally with neither ventouse, forceps or cesarean)

  • less likely to use pain relief

  • less likely to have a cesarean

  • more likely to be satisfied with their birth

  • more likely to have shorter labours

  • babies are less likely to have a low 5 minute apgar score


Amazing.... we know that continuity of care is the highest level of care for pregnant and birthing women. In the 29% stated above, 2023 saw continuity of care being offered for the whole maternity period only in OB care, private midwifery care and MGP caseload care.


OB care and MGP caseload care are hospital-based models of care, with private midwifery care having the option of exclusive in-home care without the use of the hospital setting at all.

In 2021:

  • 97% of Australian births took place in hospitals in conventional labour wards

  • 75% did so in public hospitals

  • 2% birthed in birth centres

  • 0.5% birthed at home

  • 0.7% in other settings (such as born before arrival)


Let's take a break from numbers for a quick sec and consider what this says about the birth culture in Australia: 97% of Australian women are accessing care in hospitals. Women's choices to do so are unique and individualised, some may feel safest in a hospital setting, may have high-risk pregnancies, and/or the financial component of public healthcare plays a big part in women's accessibility to models of care in pregnancy, birth and postpartum.


75% of women are accessing care via public healthcare, which arguably is a considerably lower (upfront) financial investment than private midwifery care or OB care.


What we can now start asking is: why is the hospital seen as the safest place to birth? so much so that public funding is tunneled to this model of care which directly impacts women's spread of choice in their pregnancy, birth, and postpartum care?


Let's now look at birth outcomes for place of birth and model of care in the current years in Australia


From an inexhaustive list of Australian research regarding place of birth:

  • regardless of risk status, planned home birth was associated with significantly lower rates of all obstetric interventions and higher rates of spontaneous vaginal birth

  • low-risk women had similar rates of perinatal mortality irrespective of birthplace, however, overall composite perinatal and maternal morbidities were significantly lower for those planning a home birth

  • even those planning a homebirth who then transferred to the hospital saw higher rates of vaginal birth and lower rates of neonatal NICU admission when compared to planned hospital births

  • compared with planned hospital births, the odds of normal (physiological) labour and birth were over twice as high in planned birth centre births and nearly six times as high in planned home births

  • no statistically significant differences have been found in the proportion of intrapartum stillbirths or early or late neonatal deaths between birth centre births, hospital births and home births


From an inexhaustive list of Australian research regarding the care provider models:


women in public midwifery continuity care:

  • are less likely to have a scheduled caesarean,

  • are more likely to have an unassisted vaginal birth,

  • experience freedom of mobility during labour,

  • experience informed consent processes for inducing labour, vaginal examinations, fetal monitoring and receiving syntocinon

  • and report the highest quality intrapersonal care

  • they also have fewer vaginal examinations,

  • less likely to have an epidural

  • lower odds of perineal trauma requiring sutures

  • lower anxiety after the birth

  • shorter postpartum hospital stays

  • and higher odds of a home postpartum care visit

women in private obstetric care are:

  • more likely to have their labour induced

  • more likely to have a scheduled caesarean birth

  • more likely to experience informed consent processes for caesarean

  • report high-quality interpersonal care

  • but less likely to experience unassisted vaginal birth

  • less likely to experience informed consent for syntocinon to birth their placenta


spontaneous onset of labour and an unassisted vaginal birth likelihood:

  • 58.5% in MGP

  • 48.2% for standard hospital care

  • 30.8% for private OB care


Going back to the start of this blog post: only 14% of Australian models of care in 2023 were MGP caseload care. This is based on the availability of midwives and programs in hospitals around Australia that implement such care. This means that the possibility for women to access this care (which has the highest likelihood of spontaneous labour and unassisted vaginal birth) is considerably lower than say the 41% which makes up public hospital care.


Here's a snapshot of what models of care were used in Australia in 2023:


Maternity models of care in Australia, 2023, Major model category - Australian Institute of Health and Welfare (aihw.gov.au)

I often come to the point now of asking myself: okay, rates of intervention are higher in private OB care and public hospital maternity care, but what does that really mean for the woman and her experience?


I guess, that is totally up to the woman and how she perceives her experience, her value on physiological birth, or whether she feels safer utilizing medical intervention in her labour. If this is the case though, I would highly recommend asking yourself why you feel safer using medical intervention, and whether this is rooted in the cultural conditioning around birth or if it is based on unique and personal circumstances. If it is the latter, there is still an opportunity to go deeper into this and understand more of any fear you hold around birth.


What does the research say?

Over one-third of women experience psychological birth trauma, and this can impact not only the mental health of the mother but the family relationships, including bonding with the child.


  • 4 themes have been identified in women's descriptions of what they found traumatising in their births:

  • postpartum women with indications of perinatal PTSD symptoms are found to have 44 times higher odds of screening positive for depression

  • depression, anxiety and perinatal PTSD are each independent risk factors for one another

  • evidence is strong that the mode of birth is not associated with the risk of postnatal depression

  • when women perceived supportive caregiving from their childbirth providers, their long term memories of the birth experience were positive irrespective of complicated or difficult birth events

  • a significant association has been found between women's postnatal perspective of their birth experience and postnatal depression


So, what do women want in their maternity care to avoid the outcomes described above?

A systematic review of 59 studies based in Australia from 2012 to 2023 found that four themes developed. Women want:

  • continuity of care

  • to be seen and heard

  • to be and feel safe

  • to be enabled in their experience

= what model of care are we most likely to see these themes?


Here's where I impart another PSA: THIS IS NOT MIDWIVES OR BIRTHING WOMENS FAULTS


Research shows that less than a third of Australian midwives report their workplace as a positive culture, that they feel disengaged and unsupported, and have the inability to use all of their midwifery knowledge in medically-dominated environments.


The crux of this post is to encourage you to look at the culture in which you are birthing, utilise the research as a mirror of that culture, and question where you would like to place your resources in your model of care should you have the freedom to do so, to get the experience you are wanting. Almost all of us immediately assume that 1) we will birth in a hospital and 2) in a public maternity hospital because we are rarely shown or encouraged to access the other options available. Beyond this, we assume that private health means better care because it comes at a cost, and money is the exchange of value in our modern world.


If the care you choose to go with (whether by what's available or personal choice) is one that is not conducive to positive birth outcomes, what you can then do is use this information to educate yourself and become rooted in advocating for yourself and your baby.


I will go further into how you might make this decision and what can follow in the next post. I've gabbed on for quite awhile here. See below for all research used:




 

With a special interest in natural fertility, conscious conception, and conscious relating through starting a family, I offer birth support and related services to encourage more depth and awareness in your journey. I educate on the menstrual cycle and encourage women to reawaken their confidence and trust in their bodies, and show an understanding of how all of these experiences are interrelated and must be considered on your journey to starting a family.


I share similar information regularly on my social media. Please follow to keep updated, and contact me if you'd like to talk more about this divine time of preparing for your spirit baby.


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