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I have been reading the June 09 issue of “Women and Birth: Journal of the Australian College of Midwives”. This is Australia’s national midwifery peer-reviewed journal.

There is an article entitled “Swedish Caregivers’ Attitudes Towards Caesarean Section on Maternal Request”.

I was astounded to see that the CS rate in Sweden was a mere 17.7% in 2006. Contrast this with Australia’s rate of 31% in 2006! Swedish midwives and obstetricians who were interviewed for this study displayed a conflict between resistance and respect of the woman’s decision for maternal-choice caesarean.

The Context of Swedish Maternity Care

Antenatal care in Sweden is organised within the public primary health care system with the midwife as the primary caregiver, taking care of all pregnant women in a certain geographical area during pregnancy. Care during labour, birth and the postnatal period occurs in hospitals with midwives as the independent caregiver for uncomplicated cases. Midqives work in collaboration with obstetricians if complications occur. There are no alternative birth settings in Sweden and continuity of caregiver between episodes of care is rare.

Formally, caesarean section is not an option women can choose themselves. The obstetrician has to be convinced of the need to perform surgery without a medical indication. The majority of obstetric departments in hospitals have established qualified teams who provide support for women who suffer from childbirth-related fear. If a woman wishes to have a CS, she is referred to such a team before she meets the obstetrican for the final decision.

Several things interest me about this system.

There is no private system. No private hospitals, no private obstetricians, and no private midwives. There are no birth centres. Why do we have such a range of options in this country? On the surface, it may seem logical to believe that since all women are different, they have different needs, and hence we need many options to try to keep most women happy. But are most women happy with the birth options that are open to them? Unfortunately, I’d have to say the answer is no. Sure, we have some birth centres and some midwifery models of care, we have private obstetrics or midwifery and so on, but since all of these options are not available to every woman, in some ways I think this creates even more dismay about current options.

So, we have lots of options, presumably because women are all individual and want different things. But are women happy with the current services? I’d say a resounding no. I would also challenge the opinion that women are all individual and want different things out of their maternity care. I think women all want the same thing, when push comes to shove. They want continuity of care, from someone they know and trust. They want input into their care, they want to be a part of the decisions that are made. I think the reason we have so many options in this country is that each option is woefully inadequate. Each successive option is an attempt to patch-up the broken maternity health care system. I think the more options we have, the stronger this argument is. We have birth centres because hospital delivery suites are too clinical and cold …. and most will not “allow” water birth. We have homebirth midwives because birth centre inclusion criteria are too strict or because women want consinuity of midwifery care. We have private hospitals because some public hospitals look too worn and uncomfortable to birth in. And sometimes the food leaves a lot to be desired! We have private obstetricians because women wish to know the doctor who will attend them should anything go “wrong”. And so on.

What is we simply fixed the system???

Sweden recognises and protects the role of the midwife as the primary care provider for well, healthy women. And it recognises and protects the valuable input of obstetricians when things deviate rfom normal. In this manner, they no doubt have a much larger midwifery work force, relative to the obstetric workforce that we’d see in the metropolital areas on Australia. And no doubt a more appropriate use of midwifery and obstetric resources.

Sweden provides support for women who fear birth. This is only available privately (psychology) in this country, although some hospitals also offer social work services for women who fear birth. What a great system to have in place, that women who fear birth are referred for psychological help. Afterall, do doctors routinely place colostomies in people if they fear defecation? If not, then why do they perform caesarean sections on women who fear birth?

I believe the changes that are suggested as part of the budget and the maternity services review will go a long way to reform maternity care in this country. Women will be able to access a private midwife as their primary care provider, with access to an obstetrician if needed. Birth will be in hospital or birth centre. If home birth is desired, this option will not be funded by medicare or insured – much the same as our current situation.

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