She was delivered at home after her mother, Leah, rejected advice to have a caesarean section … because her first baby … had been born that way …

A surgical birth – about 30,000 are performed in NSW each year – would have cost the public hospital system about $8000.

If she had been admitted to a neonatal special care unit, like 70 per cent of babies born by caesarean, including her big brother, it would have cost another $900 a day.

But her entry to the world, in a Dee Why lounge room, cost taxpayers nothing …

[Midwives] are calling for another urgent meeting with the Health Minister, Nicola Roxon, before the new rules come into effect in July.

For the past seven months, the state Department of Public Health declined to release a report outlining the trend.

California Watch spoke with investigators who wrote the report and they confirmed the most significant spike in pregnancy-related deaths since the 1930s. Although the number of deaths is relatively small, it’s more dangerous to give birth in California than it is in Kuwait or Bosnia.

“The issue is how rapidly this rate has worsened,” … “That’s what’s shocking.”

… “current trends and evidence suggest that maternal mortality rates may be increasing in the U.S.”

The alert asked doctors to consider morbid obesity, high blood pressure and diabetes, along with hemorrhaging from C-sections, as contributing factors.

… Shabbir Ahmad, a scientist … decided to look closer. He organized … a systematic review of every maternal death in California. It’s the largest state review ever conducted. The group’s initial findings provide the first strong evidence that there is a true increase in deaths – not just the number of reported deaths.

Changes in the population – obese mothers, older mothers and fertility treatments – cannot completely account for the rise in deaths in California …

… scientists have started to ask what doctors are doing differently. And, he added, it’s hard to ignore the fact that C-sections have increased 50 percent in the same decade that maternal mortality increased. The task force has found that changing clinical practice could prevent a significant number of these deaths.

… While the maternal mortality rate among black women is rising, the task force found a more dramatic increase in deaths among white, non-Hispanic mothers …

… In 1996, the maternal death rate in California was 5.6 per 100,000 live births … Between 1998 and 1999, the World Health Organization changed its coding system, which may have increased reporting of deaths. The California rate was 6.7 in 1998 and 7.7 in 1999. Because the number of mothers who die is small, the rate tends to fluctuate from year to year.

In 2003, when California revised its death certificate, the rate jumped to 14.6. And in 2006, the last year for which data is available, the rate stood at 16.9.

… When researchers unveiled their initial findings to a conference of the American College of Obstetricians and Gynecologists in 2007, there were gasps from the audience … The idea that California was moving backward even in an era of high-tech birthing was implausible to some. Confirmation of the trend was noted in the 2008 report …

The state of California has yet to share the report with the public. Researchers say that, after reviewing the report in 2008, officials in the Department of Public Health asked for technical clarifications. Revisions were complete and approved in the first half of 2009 …

… it is important for the public to be aware now that these trends are worsening …

“Even though they tend to be small numbers in terms of maternal mortality, it is important – it’s very important – that these trends be looked at,” she said. “And efforts need to be made to try and reverse them when they are going in the wrong direction.”

Rising C-section birth rate

Nearly one in three babies is now born by C-section. Many scientists have acknowledged that at some point, as the number of surgeries spiral upward, the risks will outweigh the benefits. But the C-section remains a useful tool, and in the middle of labor, doctors say, it’s hard to balance the potential long-term harm against immediate crisis.

Today, doctors face a condition called placenta accreta, where the placenta grows into the scar left by a previous C-section. In surgery, doctors must find and suture a web of twisted placental vessels snaking into the patient’s abdomen, which can hemorrhage alarming amounts of blood. Often, doctors must remove the uterus.

Main said this complication from C-sections has increased eight-to-10 fold in the past decade. Nonetheless, most women survive the ordeal … the rise in deaths is indicative of a larger problem.

“For every maternal death, there are 10 near misses; for every near miss, there are 10 severe morbidity cases (such as hysterectomy, hemorrhage, or infection), and for every severe morbidity case, there is another 10 morbidity cases related to childbirth,” …

Inducing labor before term more common

… Dr. David Lagrew … noticed that a lot of women were having their labor induced before term without a medical reason. And he knew that having an induction doubled the chances of a C-section.

So he set a rule: no elective inductions before 41 weeks of pregnancy, with only a few exceptions. As a result, Lagrew said, the operating room schedules opened up, and the hospital saw fewer babies admitted to the neonatal intensive care unit, fewer hemorrhages and fewer hysterectomies.

All this, however, came at a cost: The hospital had to take a cut in revenue for reducing the procedures it performed. Lagrew doubts that any hospital has increased its C-section rate in pursuit of profit, but he does note that the first hospitals to adopt controls on early elective inductions have been nonprofits.

According to a report issued by the advocacy group Childbirth Connection, “Six of the 10 most common procedures billed to Medicaid and to private insurers in 2005 were maternity related.” On average, a C-section brings in twice the revenue of a vaginal birth. Today, the C-section is the single most common surgical procedure performed in the United States.

“If all these guys were losing money on every C-section, well, what’s the old saying? Whenever they tell you it’s not about the money, it’s about the money,” Lagrew said.

… mothers should only have a C-section for medical reasons, according to the authors of the World Health Organisation study.

Women who chose a caesarean over a natural birth were 10 times more likely to be admitted to intensive care and suffer severe bleeding.

… “I do get women who ask for a C-section, often because they’ve got a pathological fear of childbirth, fears of pelvic floor problems in later life or have been sexually abused earlier in life, so they choose to have a C-section to avoid any genital tract trauma which would remind them of what’s happened.”

Dr Kliman said Epworth Freemasons had about 20 mother-requested caesareans out of 3500 deliveries a year.

“I tell them it is not necessarily an easy way out,” he said.

“They have risk of haemorrhage, infection and more discomfort after the procedure.”

Vice-president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Michael Permezel, said …”If a woman said, ‘I want a C-section’ and had no understanding of the risks, I think most doctors may decline the request,” Prof Permezel said.

They write:

…One of the problems is that the planned home birth group includes women who planned homebirth when booking in for care but then developed risk factors and had their babies in hospital. There are probably only two women whose babies died; who started labour at home planning a homebirth and one of these was a twin pregnancy (high risk). This latter woman persisted in having a homebirth due to ‘unsatisfactory hospital experiences.’ The others had all transferred before the onset of labour. The authors admit they ‘could not differentiate all planned homebirths according to whether transfer to hospital had occurred before or during labour.’ So for low risk women who started labour at home the risk was very low – 1 death in 16 years

There is no way to tell if these planned homebirths were under the care of a registered midwife.

This was not a low risk population of women – there was a high rate of post-term pregnancy … twins … and … previous caesarean section.

… There were two perinatal deaths that actually occurred at home. One baby had lethal congenital abnormalities (this was known before labour and a decision made for the baby to be born at home). The second death at home was after a waterbirth which was not found to be the cause of death but a review identified that increased monitoring may have identified the baby was in distress.

One perinatal death occurred in hospital after a transfer after the birth of the first twin. The first twin was born at home and second twin was born in hospital after a delay in transfer and subsequently died.

There were 6 perinatal deaths in the planned homebirth group where the baby was born in hospital. Presumably these women were transferred to hospital during the antenatal period as antenatal risk factors developed. Transferring to hospital if or when risk factors develop during pregnancy is appropriate practice.

Of the six deaths in hospital: one had hydrops fetalis … one death was unexplained with a cord entanglement seen after birth; one had pulmonary hypoplasia … after a early rupture of membranes; one was a growth restricted baby with an abnormal karotype … one was born to a woman who was very overdue … and underwent induction in hospital without fetal monitoring (the woman refused) and her labour eventuated in a stillbirth; and, one was a woman with known haematological … risk factors whose baby had a lethal abnormality … all these were born in hospital.

Only three of the deaths are thought to be related to perinatal asphyxia.

Three of the deaths were thought to be potentially preventable and related to the model of care. These were the baby born after the waterbirth at home; the second twin who was born after an intrapartum transfer and the baby born after being very postdates. Therefore, there were 3 deaths in 16 years – two of which had risk factors present. That means that there was only one death where there were no risk factors in the 16 year period.

… You would need more than 10,000 births at home to show clinical relevance and have some confidence in the statistical significance in relation to perinatal mortality rates. The authors acknowledge this in the paper and present their data with caution in the paper stating that the ‘small numbers with large confidence intervals limit the interpretation of these data.’

The facts are there was no difference in perinatal mortality … For those actually born at home the perinatal mortality rate is 2.5 per 1000 births, which is comparatively low.

… The paper highlights that the system must be so terrible for some women that they would choose to give birth outside of it than in it, even with risk factors. This is an indictment on the current maternity system in Australia – that needs fixing – removing homebirth won’t do this.

What was missed?

The conclusion of the paper is very sensible recommending risk assessment, transfer and fetal monitoring.

So then why did the data get so grossly misinterpreted?

The reality is despite a malfunctioning system in this country where midwives are uninsured and have no visiting rights, and homebirth is unfunded and often hard to access, the perinatal mortality rate was no different.

Risk assessment, transfer and fetal monitoring will be improved when private midwives are no longer excluded from mainstream services so we should be aiming for this not continuing the ‘witch hunt’ against private midwives.

… Some women will always choose homebirth so we should support this choice with safe responsive systems of care. The authors state that ‘women’s autonomy in choosing reproductive behaviour is a fundamental human right enshrined in Australian law’.

The excess mortality continues to be found in high-risk women and women need to be informed of this risk.

I GAVE birth to my first child last year in the … maternity ward as a public patient.

Nothing could have prepared me for my horrible birth experience – ”herding yards” does not go nearly far enough in describing the way the hospital treats new mothers and babies. The need to minimise expenditure combined with an almost zealous obsession with promoting breastfeeding created an experience so stressful that, for me, resulted in what I call post-traumatic birth disorder – a fear of ever having another child in a public hospital.

My baby was born with fairly high levels of jaundice, which results in a very sleepy baby who is unable to feed well. Bar going under the UV lights, the only means of reducing the jaundice levels is to ”flush” it out with fluid.

Now that would be fine except for the fact that mothers do not produce milk for at least two days after a natural birth and up to five days after a caesarean. Not once was I offered formula to try to provide extra fluid for my baby. Instead, I was told to breastfeed and express extra fluid in between feeds.

So, in pain after major surgery, with a baby too weak to feed well and not producing milk, I was left struggling for hours to try to provide enough fluid to help my baby.

On day four I was about to be discharged when the attending doctor told me my baby had developed ”nappy rash” and might need antibiotics. At first the doctor said it would need a cream and I would still go home that day. A few minutes later another doctor said it was a ‘’severe” rash and my baby might need oral antibiotics.

Then the head of pediatrics came to look at the rash. The attending [midwife] said they thought it was a hospital-borne staph infection, which was later confirmed. At this point I was about to have a breakdown from being exhausted, stressed and furious that no one had mentioned the staph to me.

Following this diagnosis, I was discharged from maternity and my four-day-old baby was admitted as a pediatrics patient to be given IV antibiotics. The pediatrics ward is for children only so despite just having the caesarean and still being on painkillers, I was not considered a patient. I had to sleep on a fold-out couch to continue three-hourly breastfeeds but was given no food or additional pain relief …

No perfect system

WHEN my wife fell pregnant, our GP referred her to an obstetrician without discussing any options, such as the public system, birthing centres, home birth etc. This referral sent us down the path of the private health industry. We were keen on more natural options for childbirth, but it became increasingly apparent that our obstetrician was not interested in these options. Through our own research we found out about birthing centres, and decided that this was the go for us.

… our daughter was breech. Through the birthing centre we were told of an obstetrician who manually turned babies in utero. We consulted him, and our daughter was turned. I am sure that had we stayed in the private system with our original obstetrician, we would not have been made aware of this option, and my wife would have had to endure a caesarean. This is one example of the ”over-medicalisation” of childbirth by the private health care industry.

However, the birthing centre was far from perfect. My wife gave birth at 7.10pm on a Saturday. At 9.30 the next morning we were pressured to leave. We refused, and spent our full allotment of two days in the centre. A couple of days after we left, we received one follow-up visit from a midwife. She noted that our daughter was jaundiced, and advised that we put her in the sun for 10 minutes.

Later that day I took my wife to hospital because she was experiencing pain after the birth. While we were there, a [midwife] noted that our daughter was jaundiced, and requested a blood test. The result was that she was rushed to the neonatal intensive care unit in a serious condition. An hour later the head of the unit informed us our daughter was suffering from a level of jaundice so severe that they saw it only once or twice a year, and that as a result, she could be brain-damaged and suffer hearing loss, among other issues. If I hadn’t insisted on taking my wife to hospital for her pain, I dread to think what might have been …

Happy on home front

I HAD a satisfying birth at home with the help of two lovely independent midwives. The continuity of care from our midwives has been exemplary.

When I read accounts of less-than-adequate hospital-based maternity care, I can only say that home birth is worth every cent we paid.

Improving the maternity system is simple: the Government needs to stop attempting to put independent midwives out of business.

Support midwives

MY HUSBAND and I saved our stimulus packages to pay a private home-birth midwife for the birth of our second child, due any day now. The continuity of care, with antenatal appointments in our own home, is wonderful. I feel much more comfortable ringing my own midwife with questions than I did when I was seeing a different midwife every time at the … Birth Centre …

It’s not all gloom

WHILE there is room for improvement in any hospital system, the headlines in your report unnecessarily spelt doom and gloom.

In the past 10 years I have had three babies at the public … [hospitals] Each time I have been impressed with the service and care provided …

My first baby could not attach to the breast, and … we were allowed to stay in hospital until day five after the birth. Every time I needed to feed her I buzzed for the midwife to help me, and never had to wait more than a few minutes.

With my second and third babies we went home on day two, but we were ready … Postnatally, a midwife from the hospital visited me each day for two days after the birth. The midwives were caring, knowledgeable and helpful.

Motherhood’s trauma

I GAVE birth to both my sons as a public patient … There is almost no difference between the private and public patient experience, so having private health cover was of no benefit. My doctor was away both times but the on-call obs I had both times gave good care. Of course, they’re only there for the end bit and it’s the midwives who do all the work anyway.

… my key criticism is that they sometimes forget the strangeness of becoming a mother for the first time. We are not used to being mostly naked in a room full of other people … We are flooded with hormones that leave us lost and confused. We think motherhood will be a tender and graceful time, when in fact it can often be a time, particularly the first time, when you feel frighteningly laid bare. I would have appreciated someone to facilitate a more caring and dignified transition into my new role.

A cry for help

At home, things got worse. Feeling like you’re in an evil, black hole and not wanting to look after your own baby is not a pleasant state to be in. I had enormous problems with breastfeeding, which added even more stress to my already unwell mind.

It was the visiting midwife from the hospital who was the catalyst in getting treatment for me. At first she offered me generic advice in a way that to me seemed somewhat ”hippie dippy”, so I had to persist in letting her know how bad I felt. Eventually she gave a card for the hospital’s crisis assessment team hotline. The team member I spoke to was exceptionally understanding and gave me some calming advice. The team followed up with regular phone calls to check I was OK before they were able to send out a diagnostic team, including a psychiatrist, a couple of days later. They were also responsible for my being admitted into a mother and baby unit in the hospital’s psychiatric ward soon after.

Intensive counselling, medication, individual monitoring and support finally got me back on my feet. I am now what I would consider a ”normal” happy mother.

Forgotten option

YOU seem to have left out the home birth option in your report. Provided the woman is healthy, well-informed and well-supported, there is no reason she cannot give birth at home, with the aid of a trusted midwife. My wife did so three times …

If necessary, a doctor can be called to render extra assistance, and in the rare case of complications, which usually become apparent slowly, the woman can be taken to a hospital.

63% of … mothers … agreed that public maternity units resembled ”herding yards” when asked if it was an appropriate description.

Of … women who gave birth in the public system … more than a third said leaving hospital too soon was a problem, 47 per cent felt their postnatal care was inadequate, and 48 per cent experienced a lack of breastfeeding support.

Of [the] … women who gave birth in the private system … 17 per cent said they were discharged too early, 39 per cent felt their postnatal care was lacking, and 45 per cent said they did not receive adequate breastfeeding support.

Of the … mothers who gave birth in both the public and private systems, 43 per cent thought the private system was better; 30 per cent thought the public system was better.

… providing midwives with more independence to prescribe drugs would improve the system.

62% … said Australia’s 30 per cent caesarean rate was too high. A quarter thought it was mainly done for professional liability reasons and a fifth believed it was done at a mother’s request.

47% … said there was a shortage of midwives …

WHAT MOTHERS SAY
”There should be more continuity of care. Knowing your carer and trusting your carer removes the fear from childbirth and fear leads to more interventions.”

… ”There is a severe shortage of birth centre places available and in many areas it is not even an option.”

”There are so many time limits imposed on women which completely disregard the natural progression of labour in women’s bodies. Doctors are too quick to intervene, too impatient to wait and allow the body to do its job.”

… ”Women are not being given enough time to labour naturally.”

“I was not supported well enough to have a vaginal birth. I felt like they were more concerned with getting me in and out quickly so they could free up beds.”

The doctor was convicted of practicing midwifery without a licence and conducting a delivery though she was not qualified to do so …

The … hospital where the doctor worked was fined … for appointing her and making her work as a midwife though it was known that she did not have a licence. The hospital … failed to provide first-class healthcare for newborn babies and this caused the girl’s complications to grow worse, resulting in the disabilities.

Professor Lesley Barclay … is a leading proponent of the need to reorient maternity care around the needs of women and babies …

“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 …

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” … incorporates their social and emotional needs. It puts them – rather than the professional or the service …

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.

… 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.

… caesarean birth is rapidly becoming a life threatening procedure itself because of excessive use … 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 …

… 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 … 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?

… 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 …

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 … can chase evidence themselves, or question doctors, hospitals and midwives …

… 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.

… 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.

…. 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.