A recent study from QLD has surveyed 20,371 women who recently gave birth. Experiences of pregnancy, labour, birth and after birth care were assessed for the most recent birth, retrospectively four to five months after birth. The findings were very interesting! The only issues with the data and study is that mothers self-reported their answers and there was no verification of the information, or cross-checking with the midwives and obstetricians who provided the care. In other words, it was based on women’s subjective experiences rather than what might perhaps be factual or accurate. That being said, I wanted to draw a few points out of the study and elaborate more on them. The other aspect to raise is that I am making an inference when I write about this study: the study compared women who were cared for in public facilities (public hospital delivery suites and birth centres: women who for the most part would have had public care providers) with women who gave birth in private facilities. Those women would, for the most part, have booked with a private obstetrician and given birth under their care. So from this, I am inferring that public care = care from public hospital staff where the woman does not choose her care provider; and private facility care = private obstetric care. Care during Labour and Birth Most women received labour and birth care from a midwife, and saw an average of 2.3 different midwives during their labour and birth. This is an interesting fact to consider, as many women believe they will have only one midwife in labour. The reality, in a hospital (public or private) is that midwives work in shifts, and there are three shifts in a day. Private midwifery and to a lesser degree, caseload models, do not work so much on shifts (although with many caseload models, the midwives are on-call for 12 hours at a time, so it is possible that you will go through two shifts of midwives even if you are only in the birthing facility for say 6 hours). Private midwives work their time around your labour, rather than the timing of a shift.
Half of all women who birthed in public facilities had never met any of their labour and birth care providers before, and this was significantly less common among women who birthed in private facilities because their obstetrician would be present for the birth, representing a familiar face. This is also an interesting point to raise: many women believe their obstetrician will be there with them during labour, or at least in the birth unit. This is not the case for the most part. For the most part, your obstetrician will be in the operating theatre, in his/her private consulting rooms or sleeping (eg if you’re labouring at night) and s/he comes in only if there is a problem and of course for the birth. Therefore, although there is continuity of sorts (the obstetrician you booked with will attend the birth), your actual care (which may be several hours) would be with midwives you have not met before, who all work in shifts. In contrast, private midwifery care is delivered by the midwife you booked with. Your private midwife would be there with you for the duration of your labour.
The majority of women in the study wanted to have a vaginal birth. Among women who wanted a vaginal birth, women who birthed in public facilities were more likely to have a vaginal birth than women who birthed in private facilities. This might be a reflection of the choices that women make, or of the recommendations of the woman’s care provider. For the purposes of the study, the private setting would have equated to private obstetric care because private midwives cannot admit directly to a private hospital. The possibility that obstetricians are influencing a caesarean rate of almost 50% in private hospitals in QLD was quite alarming, because many obstetricians would like us to believe that the caesareans that are performed are dome so because the women ask for them or because they are genuinely needed.
The truth is that with a study such as this, we will never really know. The women were surveyed 4-5 months after the birth of their baby, not before the birth. Before the birth, they may well have asked for a caesarean, but afterwards experienced too much bleeding, wound infection, pain, complications, separation from their baby and breastfeeding issues and come to regret their decision to pursue an elective caesarean. In this case, some women might have named their care provider as the one who recommended the caesarean, rather than admitting to themselves that they chose it. That is one view.
Personally, I do believe that some obstetricians have influenced the almost 50% caesarean rate. I believe this because every day I meet women who have birthed with, or are about to birth with, a private obstetrician. They tell me that they are scheduled for a caesarean, not because they have chosen this, but because it has been recommended to them. Sometimes the intention of the “recommendation” is to assist with “informed decision making”. This is where things get a bit muddied. The woman comes away believing the caesarean has been recommended, whereas the obstetrician interprets it as providing information to the woman so that she can then make an informed decision, and then reports that the caesarean was the woman’s choice. In any event, there are ways of wording things to illicit a response or decision that favours our bias. Some are more skilled at this than others.
For example, if I told you:
Caesareans have been shown in some studies to be safer for the baby, and given that your last labour was quite long and difficult, resulting in a painful forceps delivery with an episiotomy, you might like to consider a caesarean this time. Your baby would be spared the use of forceps, so he may well feed better than your last baby, because he won’t have a headache. You are also less likely to experience any pelvic floor issues. Most likely, given that you had an episiotomy last time, I might have to perform one again. I would try not to do this, but sometimes it is necessary. I know how painful the recovery was for you last time, so a caesarean might be preferable. Yes, you would still have stitches either way, but it’s far more comfortable having stitches on your tummy than your perineum.
Given this “information”, would you choose a caesarean? Possibly as this care provider has given some good arguments (some factual and others not so factual) for a caesarean, and has used emotive and persuasive language that plays on this woman’s traumatic last birth.
Now consider a different conversation:
Caesareans have been shown in some studies to be more harmful for the baby in terms of breathing difficulties and the need to admit the baby to the nursery. This would mean that you would be separated from your baby, and I know that after your last experience, you want nothing more than to hold your baby when he is born. Given that your last labour was quite long and difficult, resulting in a painful forceps delivery with an episiotomy, we can talk through some ideas to try that will minimise the risk of tearing. I believe that an intact perineum (no stitches) is absolutely possible for you. Also, there are many courses - such as Calmbirth - that will help you to manage the sensations of labour, along with labouring in a deep, warm bath. You know, I wouldn’t be surprised if you find you don’t even think of having an epidural this time! I know you’re worried that your baby might have a sore head and be a difficult feeder if forceps are needed, as this is what happened last time, but I’d like tor reassure you that forceps are really unlikely. Your body has birthed before and it will remember what to do this time. It would be very unusual that forceps would be needed again. This is a different pregnancy, different baby, different place of birth and different care provider. We can work together to make this experience very different – and very healing – from last time.
Given this “information”, would you choose to try a natural birth? Possibly as this care provider has given some good arguments for a natural birth, and has used emotive and persuasive language that plays on this woman’s traumatic last birth.
So, that is how it comes to be that women go with the recommendations of their care providers, and all the while, the care provider believes that it is the woman’s decision, while the woman believes it’s the care provider’s recommendation. If you’re now feeling very confused and like you don’t know who to trust anymore, my word of advice would be to interview a few midwives and obstetricians and ask lots of questions of them, and then go with the care provider that feels right for you. Also ensure that their statistics (birth outcomes) are aligned with the sort of birth you are trying to achieve. Once you have done this, trust your care provider and follow their advice if their advice makes sense to you and feels right. If it doesn’t, speak up and let them know.
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