Physiological third stage

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No previous study has focused on true physiological third stage for women at low risk of postpartum haemorrhage. Physiological third stage is often chosen by women who birth at home or with a private midwife, however hospital policies urge active management of the third stage (injection of syntocinon, immediate clamping and cutting of the cord and then pulling the placenta out) because studies have shown that this form of management reduces bleeding. However, those studies have either a) not clearly defined physiological management or b) not managed the "physiological" third stages in a physiological manner.

This study clearly defines what is meant by physiological management and also the women who are suitable for physiological management. Some women are at a higher risk of PPH and so active management was recommended to those women in the study.

The study compared active management which was standard at the tertiary hospital, with physiological management which was the norm at the free-standing birth centre. At the tertiary unit, 11.2% low-risk women experienced a PPH. At the midwifery-led unit, where physiological management was practiced, PPH only occurred in 2.8% women. Active management was associated with 11.5% PPHs compared with physiological management which was 1.7% PPHs. Active management was associated with a seven to eight fold increase in PPH for low-risk women.

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Do obstetricians and midwives attract different clientele?

New research has suggested that women who see themselves as active participants in the birth of their first child, and prefer a collaborative role with their healthcare provider are more likely to opt for a planned home birth with a midwife. On the other hand, women who perceive their role in the birthing process more passively and are more fearful of birth are more likely to seek obstetric care for a hospital birth.

Women's answers indicated whether they perceived the Mother’s Role as active or passive, the Provider’s Role as dominant or collaborative, and the Delivery Experience as fearful and painful, or as a positive occurrence.

Women who perceived their role as active, the provider’s role as collaborative, and the delivery of the child as a positive experience, were more likely to prefer midwifery care, birth at home, a vaginal delivery and the avoidance of pain medication.

The more painful and fearful a woman expects her birth to be, the more likely she is to prefer a caesarean to a vaginal birth.

Melissa Maimann is an endorsed eligible midwife in private practice in Sydney.  One of the first eligible midwives in Australia, Melissa now offers a range of care options for women including private midwifery care and birth support.  Visit Melissa's website to learn more about her services.

First time mums and homebirth

What a great choice!  Discuss your situation with your midwife for more advice. Generally, first babies are ideal for home births. Why? Most first births go really well with the care and support of a midwife.  In the hospital system, a first-time Mum stands a 25% chance of having a caesarean, a 25% chance of needing forceps / vacuum, and only a 50% chance of a normal birth.  Compare this with the chance of a normal birth at home with a private midwife (around 90%) and you can see why there is such a benefit to planning to birth your first baby at home.

Melissa Maimann is an eligible midwife in private practice in Sydney.  One of the first eligible midwives in Australia, Melissa offers a range of care options for women.  Visit Melissa's website to learn more about her services.

 

Knowing Your Midwife

For many women, pregnancy can be an emotional rollercoaster.  Many women experience excitement, joy and hope, but also fear, uncertainty and even disappointment and sadness. The relationship a woman develops with her midwife is important to a woman as she journeys through her pregnancy, birthing and in the early weeks with her baby.

It has been shown that women who are cared for by one dedicated midwife for the duration of their pregnancy, birth and early newborn period find this form of care to be highly satisfying.

It is about having one person who shares in your pregnancy, who listens as you share your fears and concerns, who shares information with you and who supports your decisions and choices.

When a woman knows and trusts her midwife, there is a shift of power towards the woman as she feels a greater sense of control over her entire experience.  She becomes aware of her choices and options, she feels confident to make her own decisions and she goes to her birth feeling confident, informed and supported.  She knows who will be caring for her on the day, and she knows that her midwife knows everything that is important to her for her birth.

There is no sense of being a number in a busy system.  There is no need to repeat yourself at every visit.  There are no lengthy waits for appointments.  Each appointment takes around an hour, so there is plenty of time to get to know one another.

Private midwifery care is an option that more and more women are asking for, although it is only accessed by a small number of women.  Yet research shows that this care model, in which a woman is cared for by one midwife from early pregnancy though to birth and post-birth care, offers numerous benefits to women and babies. These include a greater chance of a spontaneous birth without stitches, feeling in control during labour and exclusive breastfeeding with minimal chance of postnatal depression and baby blues.  Private midwifery care also means much less requirement for pain relief in labour, fewer inductions of labour and of course a much lower chance of needing a caesarean.

The care I am describing - where a woman knows and chooses her midwife – is available for both home and hospital births.  If private midwifery care is available in your area, you may decide that is what you would like.

Melissa Maimann is an eligible midwife in private practice in Sydney.  One of the first eligible midwives in Australia, Melissa offers a range of care options for women.  Visit Melissa's website to learn more about her services.

How do midwives monitor the baby's heart beat in labour at a homebirth?

Midwives monitor a baby's heart beat in a home birth, as well as ensuring the health of the woman giving birth.  The usual method of monitoring a baby at a homebirth is for the midwife to use a doppler.  This portable and light-weight piece of equipment is water-proof, so the woman can be in any position and also in the bath or shower while it is in use. Current guidelines recommend that a baby's heart beat be listened to every 15 minutes in the first stage of labour, and after every contraction during the second stage of labour.

Some women are keen to avoid ultrasound, and the hand-held doppler does use ultrasound.  in lieu of this, the midwife can use a pinnards stethoscope, however this can only be used on land, so it would require the woman to leave the bath or shower so that the midwife could check on the baby's wellbeing.

If the midwife detected anything untoward in the baby's heartbeat at home, s/he would arrange for the woman to be transferred to the hospital where a CTG monitor could be used to give more information abut the health of the baby.  This is the same process that a birth centre midwife would employ.

Melissa Maimann is an eligible midwife in private practice in Sydney.  One of the first eligible midwives in Australia, Melissa offers a range of care options for women.  Visit Melissa's website to learn more about her services.

Homebirth transfer rates: cause for concern?

What is a woman really asking when she asks her midwife what the midwife's transfer rate is? Women often interview several private midwives when they are choosing the right midwife for their needs. Women will ask many questions of their prospective midwife, and one of the more common questions is, "What is your transfer rate?" meaning, "what percentage of the women who book with you for homebirth, end up transferring to hospital?"

On the surface, this seems like a fair question. But what is the woman really asking? I consider that the woman is really asking, "If I book with you, what's my chance of being transferred?" and when women ask the same question of several midwives, they are most reassured by the midwife with the lowest transfer rate because they perceive that they have the lowest chance of transferring if they go with the midwife with the lowest transfer rate.

Is it a fair assumption to make, that the midwife's transfer rate, representing her previous client's outcomes, are a valid guage for the current woman's likelihood of transfer? Often I find that transfers can't be predicted at the time a woman books-in for care. If we could predict it, we'd recommend a planned hospital birth. Considering transfer rates from this perspective, a midwife's transfer rate has no bearing on the current woman sitting with her. As well as this, some transfers occur because the woman has requested it - eg a request for transfer for an epidural, but not on the advice of the midwife as the labour is actually progressing very normally. The other situation that can arise is that the midwife forsees problems occurring and makes some recommendations to avert those problems, but the woman considers the recommendations and declines to follow them. In these cases, again, the midwife's transfer rate has no bearing on each new client who interviews a midwife.

What's a "good" homebirth transfer rate?

Well, many might argue that the lowest transfer rate is the best transfer rate. You're setting out for a homebirth, right? So why go to the midwife with a "high" transfer rate?

I did some scouting around on the internet and found that transfer rates range from 10% through to 50%. The Netherlands has a transfer rate of 52%! This surprised me. In the Netherlands, 86% women start in "primary" care (midwifery care), 28% are transferred in pregnancy and 17% are transferred in labour, leaving 41% women birthing with midwifery care. Of this 41%, 30% occurred at home and 11% occurred in hospital.

The St George hospital homebirth program reported a transfer rate of 37% for its first 100 births and this was in a low-risk clientele (at the start of pregnancy). Their outcomes were excellent, however and the satisfaction of the women and midwives using / working in the service was very high.

Private midwives' transfer rates vary - anywhere from 10% to 40% in some States of Australia as well as overseas. So there's a wide fluctuation. What can we deduce from these transfer rates?

Well, with the exception of the Netherlands - which has large numbers - we can't really deduce very much at all. You never can when you're dealing with small numbers. Private midwives in Australia typically don't attend more than 25-30 births a year, and some as few as 5 births a year. One transfer in 5 births is 20%, whereas if that same midwife had attended more births without complication, perhaps the transfer rate would have only been 10%.

There are a couple of things to consider with high and low transfer rates: 1. The risk status of the women at booking 2. The midwife's adherence to safety and risk management guidelines and her outcomes.

The midwife with the lowest transfer rate might simply have a low transfer rate because she only attends very low risk women: women who have birthed without complication before, who have no health history and who have no problems in their current pregnancy.

The midwife with the high transfer rate might not be transferring willy-nilly, she might just be taking on a higher risk group of women and adopting a wait and see approach - eg, "yes, you have a family history of high blood pressure and you've had it with every pregnancy thus far, but let's try some preventative measures and see what happens this time", and continue with homebirth plans. If this woman's blood pressure went up, she would have been transferred, contributing to the midwife's "high" transfer rate. The low risk / low transfer rate midwife might not have accepted this woman for homebirth at all, hence the difference in transfer rates.

The other thing to consider with transfer rates is the midwife's commitment to safety and risk management. Some midwives may have low transfer rates because the decision to transfer is prolonged, or because risk factors are denied. Is it good to have a low transfer rate if women or babies have been compromised?

But getting back to the question, "If I book with you, what's my chance of being transferred?", this question is impossible to answer. 1. We can't tell the future. Family history and health history might shine some light on possible issues for the pregnancy, but not necessarily. We can't predict all the paths a pregnancy can follow. 2. A woman's determination to move towards - and remain in - a state of health and wellness is a life-long journey that pre-dates the pregnancy. 3. Although midwives will make recommendations with the aim of homebirth in mind, it is the woman's right to consider the advice and decline it. Declining a midwife's advice may well mean that a transfer will become necessary. 4. Midwives' statistics are only relevant to her past clients, not the client sitting with her currently. 5. For many midwives, the goal is really safety: safety for woman and baby. We strive to achieve the safest birth in the setting that can best meet the needs of our client.

Melissa Maimann is an eligible midwife in private practice in Sydney.  One of the first eligible midwives in Australia, Melissa offers a range of care options for women.  Visit Melissa's website to learn more about her services.

5 myths about homebirth

1. Home birth is unsafe

Numerous studies have shown that a home birth is at least as safe as hospital birth for healthy, low-risk women, who are attended by midwives, with back-up plans in place.

2. Home birth is messy.

Many homebirths occur in water, and the birth pool is simply drained after the birth and everything stays very clean!  However, if you are birthing out of the water, your midwife will provide you with a list of homebirth supplies that you will need, and this will include such things as towels, sheets and plastic to protect floors, lounges, beds, carpet and so on. Garbage bags are always available and midwives always leave the house as they found it after the birth.

3. What if something goes wrong? "I / my baby would have died if we had had a home birth!!!"

How many times do we hear hear this?  Provided the homebirth is "low risk"and there is a midwife in attendance, the chance of things going very wrong is very very small.  The important issue is to ensure that good care has been provided in pregnancy, that there are back-up plans in place and that the woman and her baby are healthy at the start of labour.  In this group of women, homebirth is at least as safe as hospital birth, for both mother and baby.

If things take a different path in the labour, the midwife is often able to manage issues with simple measures. If more complicated measures are needed, the midwife will take the woman into hospital.  Most studies show that this happens in less than 15% of home births.

Typically, midwives bring a range of safety equipment and supplies to a birth. These include: - Oxygen - Suction equipment - Suture material and local anaesthetic for tears - Medication to stop any excess bleeding after the baby is born - Vitamin K for the baby - A doppler to monitor the baby's heart beat - Blood pressure equipment - Urinalysis sticks - Scales to weigh the baby - Resuscitation equipment for the baby - An oxygen mask for the mother - A catheter in case the mother is unable to pass urine - General equipment such as gloves, a mirror, needles and syringes, sterile water and normal saline, gauze, cotton wool, tape, cord clamps (unless the family prefer to use a cord tie) and so on. It's quite a big kit when it's all put together!

4. Only hippies have home births.

This couldn't be further from the truth! The general profile of a homebirthing family goes something like this:

- tertiary educated - in their 30s - already has one child or has been researching birth for many years - works in professional or managerial industries And many are from a health background.

5. It's expensive to have a homebirth.

Costs range from $3000 to $6000 which is very little when you consider what it covers, and the fact that it is spread over about 9 months of care.  After Medicare benefits have been claimed, the out-of-pocket cost is much lower than this. 

Care includes things such as:

  • antenatal (pregnancy) care
  • postnatal care for 6 weeks
  • labour and birth care at home or in hospital
  • your own midwife being on-call 24/7 from the time you book in until 6 weeks after your baby is born
  • access to a library of books and DVDs

Melissa Maimann is an eligible midwife in private practice in Sydney.  One of the first eligible midwives in Australia, Melissa offers a range of care options for women.  Visit Melissa's website to learn more about her services.

What are the benefits of a water birth?

Waterbirth is a popular way to birth a baby.  I find that few women will have a waterbirth for one baby and choose a land birth for a subsequent baby, however many women will have a land birth with one baby and then opt for a waterbirth the next time.  Occasionally a woman will choose a homebirth specifically so that she can experience a waterbirth, perhaps because her local hospital may not support her in this.  Waterbirth is an effective way for a woman to manage the sensations of labour and may lead to a shorter labour.

Waterbirth results in fewer perineal tears because the water has a softening effect on the perineum and because women are better able to assume birthing positions that minimise pressure on the perineum.

Waterbirth helps a woman to be more active in her labour and birth because it helps with a sensation of weightlessness.

Babies who are born in water are often calmer than babies who are born on land.  Some don't cry at birth: they are pink and breathing and their cords are pulsating, but they are very calm and simply look around and take in their new surroundings.

Labouring in water has also been shown to lower a woman's blood pressure and assist with dilation of the cervix in a labour that is considered to be "slow".

In my practice, about 50% women birth their babies in water.

Melissa Maimann is an eligible midwife in private practice in Sydney.  One of the first eligible midwives in Australia, Melissa offers a range of care options for women.  Visit Melissa's website to learn more about her services.

What equipment do women need for a homebirth?

A while back, we looked at what equipment midwives bring to a homebirth.  But there are also a few things that women will need to supply for a homebirth.  Most of the items are inexpensive and are found around your home, so it's really just a case of gathering the supplies together.

  • Face washers
  • 3 old bed sheets: one for the bed, one for the couch and one spare
  • 15 old towels (especially if you're having a waterbirth)
  • 3 large plastic sheets (eg painter’s drop sheets or plastic shower curtains) for covering the couch, bed and for under the birth pool.
  • Plastic supermarket bags for rubbish
  • Plastic container with lid for placenta
  • Large rubbish bin for rubbish
  • Laundry basket for soiled towels
  •  Fan
  •  Candles and matches (optional)
  •  Pillows and bean bags for comfort (optional)
  •  Loose clothes and comfy socks for labour
  • 4 packets maternity pads
  • 2 packets regular pads
  • 1 box of tissues
  • Massage oil
  • Hair bands
  •  Mirror for you to see the birth
  • Music
  • Bendy straws
  •  Baby clothing, jumpsuits, singlets, etc
  • Nappies
  • Cotton wool balls
  • 6 baby wraps
  • Thermometer
  •  Birthing pool
  • Electric pump for pool
  • Hose for filling
  • Connections for hose
  • Mattress or couch to lie on that is close to the pool (cover in plastic)
  • Hand-held colander for “floaties”
  • Camera and/or video recorder
  • Snacks and drinks
  • Present from sibling/s for the new baby

All in all, most of these items are found at home, and your midwife will bring all the medical equipment that is needed.

Melissa Maimann is an eligible midwife in private practice in Sydney.  One of the first eligible midwives in Australia, Melissa offers a range of care options for women.  Visit Melissa's website to learn more about her services.

Physiological (natural) third stage

The third stage of labour begins once the baby has been born, and ends with the birth of the placenta. Many women are now requesting a physiological (natural) birth of their placenta, especially following a natural birth.  A safe physiological third stage requires oxytocin to be produced by the mother to stimulate the uterus to contract and expel the placenta.  Generally, this requires:

  • Natural birth: without medication to induce or augment (speed up) the labour, without an epidural, without forceps, vacuum or caesarean.  So, in other words, a labour that starts on its own, progresses on its own, where the mother does not use medical forms of pain relief, and where she breathes out or pushes out her baby unassisted by forceps or a vacuum (or caesarean).  This is because these natural processes prime the woman's body to release lots of oxytocin once the baby is born, to stimulate the uterus to contract to expel the placenta.
  • An environment that supports oxytocin release: this would be a private, dark, calm, warm, quiet environment with a known and trusted care provider.  Not the hustle and bustle of a busy delivery suite, but perhaps a water birth setting, home birth setting, or a birth centre setting.
  • No distractions: the mother and baby should be left (but observed by a midwife) for uninterrupted skin-to-skin contact, bonding time and breastfeeding if the baby is ready for this.
  • Leave the cord!  No-one should be fiddling with the cord, checking pulsations or pulling on the cord.  So long as the bleeding is not excessive, the woman should be left and observed.

In time, the placenta will emerge.  Often the woman feels more contractions and an urge to push.  If she is upright (eg squatting, sitting on the toilet, standing or kneeling) the placenta will come on its own, or perhaps with a gentle push.  It can be supported as it emerges and collected into a bowl, ice cream container (sans ice cream) or other receptacle.  The midwife would then check the placenta and membranes to ensure that they are complete.

Melissa Maimann is an eligible midwife in private practice in Sydney.  One of the first eligible midwives in Australia, Melissa offers a range of care options for women.  Visit Melissa's website to learn more about her services.

Home birth: how messy is it?

Homebirth generally isn’t messy at all.  Many women birth in a birth pool and any bodily fluids are easily contained.  Towels and plastic sheeting come in handy and are strategically placed to catch any mess.  And midwives are very good at leaving the house as it was found.  Plastic bags collect any garbage, the placenta is collected in a bowl or container, and sheets and towels can be washed.  All in all, a homebirth is nowhere near as messy as people think.

Melissa Maimann is an endorsed eligible midwife in private practice in Sydney.  One of the first eligible midwives in Australia, Melissa now offers a range of care options for women including private midwifery care, antenatal shared care and birth support.  Visit Melissa's website to learn more about her services.

What does it cost to have a baby with a private midwife?

It's a common question asked on forums and social media, and a good question to ask.  Fees vary between different private midwifery practices, and depend on many factors. 

Sometimes, people comment that private midwifery is very expensive.  I think it is easy to form this view when people are not familiar with what goes into the cost of providing care.  Actually, when you work out an hourly rate for all of the care, it is very low.  Much of the work of a private midwife is invisible to families, so it is understandable that the cost might seem high.

I have prepared the following information to explain what goes into the cost of providing private midwifery care.  Before we start, there are a few things I'd like to point out:

  1. Private midwifery services (whether for hospital birth or home birth) are very comprehensive, and private midwives spend many hours with women and their families, one-on-one, building a relationship during the pregnancy that carries through to the birth and beyond.
  2. When a woman books with a private midwife, the midwife herself is on-call 24/7 from the moment of booking and until the baby is 6 weeks old.  This is not the same as a group practice arrangement where the midwife is on-call for 12 hours at a time and with holidays scheduled in as well as days off, or a group obstetric practice where your obstetrician works only one weekend in four.
  3. Appointments are generally around an hour long, compared with standard hospital services and private obstetric services where visits may be around 10 minutes.

So .... what exactly goes into the cost of providing care for a family?  I'll break it down to the visible costs: those that a woman can appreciate each visit; and the invisible costs: those that are incurred behind the scenes.

Visible costs

  1. Time: consultations, birthing
  2. Program handouts
  3. Library of resources

Invisible costs

  1. On-call - 24/7
  2. Travel time to home visits and births
  3. Research
  4. Professional consultation with other professionals on the client’s behalf (eg medical consultation)
  5. Office (computer, fax, copier, scanner, printer, phone)
  6. Policy development: private midwifery practices are required to have written policies
  7. Auditing
  8. Reporting
  9. Preparation of a hospital booking
  10. Referrals to medical staff if required
  11. Continuing professional development (eligible midwives are required to undergo at least 40 hours of professional development each year)
  12. Professional Practice Review
  13. Membership of professional bodies and organisations
  14. Registration
  15. Administration
  16. Data entry for auditing
  17. Care Program development
  18. Consulting room lease / purchase
  19. Insurance
  20. Postage
  21. Parking
  22. Tolls
  23. Merchant fees
  24. Stationery and printing costs
  25. Birth kit
  26. Midwifery equipment
  27. Oxygen and suction

As you can see, the service provided by a private midwife is comprehensive and does not compare easily with other maternity services in terms of continuity of care, hours of contact, follow-up and availability. When you choose a private midwife for your pregnancy and birth, you are choosing gold standard service.

Also, when midwives provide this level of service, it is impossible to book more than two or three clients each month without anticipating clashes in births and attendance for urgent issues that come up.

I think that private midwifery care is a fantastic choice for women who are after comprehensive, value-filled, smart care.  It is a model of care that is backed by international research as being gold-standard care for mothers and babies.

Melissa Maimann is an endorsed eligible midwife in private practice in Sydney.  One of the first eligible midwives in Australia, Melissa now offers a range of care options for women including private midwifery care, antenatal shared care and birth support.  Visit Melissa's website to learn more about her services.

 

Choosing Your Midwife

Midwives are qualified and educated to care for women throughout normal pregnancy, birth and the postnatal / newborn period. Finding the best midwife for your needs can be a challenging task, but it’s one of the most important decisions a family will make when they decide to work with a midwife.

The midwife’s knowledge, skill and experience are key to a safe and satisfying pregnancy and birth experience. When engaging the services of a private midwife, most people will make contact by phone call or email, and then arrange for an initial consultation. At the consultation, the midwife and family interview each other to explore whether the relationship feels right for them and meets their needs. Midwives will ask about the woman’s health history, her care needs, her previous birth experiences, her attitudes and beliefs about birth and her expectations of her midwife.

What sorts of questions can women ask their midwife? Well, there are lots of questions you could ask and I’ve included some below.

Be sure to ask about qualifications and experience, including whether your midwife is an eligible midwife. You are able to claim medicare benefits if your eligible midwife has a collaborative arrangement and is able to access obstetric care for you if it becomes necessary. If you are told, “I have three years of experience” ask where that experience was obtained – in a hospital? Private practice? If in private practice, how many births does she attend a year? 2? 20? Generally for private practice, the more experience that is gained, the better: when a midwife works in private practice, she works alone and needs a good level of skill, experience and judgment to practice safely. Experience is always the best teacher.

Ask your midwife about her relationships with hospitals and doctors. This will provide insight into your midwife’s ability to negotiate and communicate.

Many women ask for references and testimonials but this can be tricky as registered health practitioners are forbidden from displaying testimonials on websites. You can ask your midwife if she has any former clients who would be prepared to speak with you, but be mindful of confidentiality and women's rights to privacy.  What your midwife can do, is to provide a summary of the feedback that she has received from her clients. This will tell you that your midwife is engaged in quality assurance processes and would also provide a way of reading feedback from previous clients.

Ask your midwife what her service includes and does not include. Also ask about fees, back-up arrangements and obstetric back-up arrangements.

Finally, it’s really important that you feel comfortable with your midwife and that you feel that you trust her. Reliability is important, as is trust, respect and honesty.

Visit my website to learn more about private midwifery care.

The Home vs Hospital debate

There has been a lot in the media lately about homebirth vs hospital birth.  I read two excellent articles recently: Childbirth: why I take the scientific approach to having a baby and Why do parents choose to have a Homebirth?

I think that what has been highlighted is the availability and access to high quality information that women can use to base their decisions.  It also requires that choices are available and supported.

 

 

5 thuths about private midwifery care

1. Your chance of caesarean is about as low as it can get

  • Approximately 5%, with almost all studies pointing to rates less than 10%, and some as low as 3%

2. The most likely outcome for you and your baby will be:

  • Your labour will start on its own
  • Well prepared, confident and supported, your labour will not need any form of medication to stimulate it once it has started
  • You will require no medical forms of pain relief
  • You will reflect positively on your birth
  • You will birth normally, and without the need for stitches
  • You will exclusively breastfeed your baby with minimal problems
  • You and your baby will experience optimal health and recovery from birth

3. It is an excellent investment in your health and that of your baby

4. While many women will change from one model of care to private midwifery care, few women change from private midwifery care to another model.

5. Private midwifery care means complete continuity of care.  Your midwife is not restrained by a shift duration, she will not be on annual leave with you give birth and she will personally attend you at the times that you need her.

Learn more about private midwifery care and antenatal shared care

Can it be that home is a safer place for birthing than hospital?

A study has found that planned, low-risk, midwife-attended homebirths are less risky than planned, midwife-attended, low-risk hospital births, and this is especially the case for second-time mothers.

A large Dutch study found that the risk of serious complications was one in 1,000 for homebirths, and 2.3 in 1,000 for hospital births.

For low-risk women having their first baby at home, the chance of being admitted to intensive care or needing a blood transfusion was slightly less than for women giving birth in hospital, being 2.3 per 1,000 for homebirths, and 3.1 per 1,000 for planned hospital births.

For women who had given birth before, the chance of a postpartum haemorrhage was 19.6 per 1,000 for a planned homebirths and  37.6 per 1,000 for planned hospital births.

However, other studies have found hospital birth to be safer.  How can it be that this study (amongst others) has found homebirth to be safer than hospital birth?  The answer lies in who births at home, who attends those women and the systems available to support the homebirth.  It seems that when low risk women choose to birth at home, cared for by their own midwife, with a system in place for obstetric consultation or hospital transfer if necessary, the outcomes are actually better than those for women who choose hospital birth.

Reasons that women don’t engage private midwives

  1. She doesn’t know what a private midwife does. A private midwife is a midwife who works in a private practice.  Women who elect to be treated as private patients choose their care provider, so this means that a midwife who works in private practice works with women in the private health system providing complete continuity of care.  Private midwives usually consult with women in the midwife’s office or consulting rooms, or in the woman’s home.  Private midwives attend births in women’s homes, in birth centres and in hospitals.  They work with doctors to ensure that women and babies receive the very best care possible.
  2. It’s not recommended by their doctor. If your doctor is recommending against going with a private midwife, this could possibly be due to a lack of awareness of the ways in which private midwives work.  Your private midwife is able to contact your doctor to explain more about the way that private midwifery care is offered.  Many doctors remain unaware that there are Medicare benefits for care with eligible midwives in private practice, and that eligible midwives in private practice may order all the tests and scans that are needed during pregnancy, birth and in the care of a new baby, as well as ordering the necessary medications relating to pregnancy, birth and postnatal / newborn care.
  3. She doesn’t plan to have a home birth. Many women erroneously believe that one would only engage a private midwife for a homebirth.  Certainly, there are midwives who do work exclusively in home births, however many private midwives attend births wherever the woman feels is safest for her, and this may well include birth centres and hospitals.
  4. Only hippies would choose a midwife. Private midwifery care is not chosen by any particular group of women.  Women from all walks of life choose private midwifery care.
  5. She worries that private midwives cost too much. Cost is certainly an issue for some families.  Medicare benefits are available for services provided by eligible midwives in private practice.  Through my service, there is a range of options available with costs starting from $0 (after claiming back through Medicare).

Learn more about private midwifery care and antenatal shared care.

Birthing statistics

The statistics listed below are for the births I have attended at home, in birth centres and in hospitals.  They reflect the care that has been provided to women in my care and may or may not represent your individual experience. The number and type of interventions in a birth will depend on many factors:

  • Health and safety factors
  • The decisions that are made by a woman and her care provider
  • A woman's motivation to achieve the birth she has planned

Statistics:

  • Normal birth (no forceps, vacuum or caesarean): 89%
  • Caesarean 5%
  • Vacuum 3%
  • Forceps 4%
  • VBAC 88%
  • Episiotomy 3%
  • Intact perineum 65%
  • 5% women use an epidural for labour
  • 82% women use no medical forms of pain relief in labour
  • 12% women are induced
  • 50% women have a waterbirth
  • 49% women birth at home
  • 60% women have a physiological third stage
  • 97% babies are exclusively breastfed at 6 weeks discharge
  • Homebirth transfer rate 19%
  • Women considered to be "low risk": 45%
  • Women considered to be "high risk": 55%

Statistics for first babies:

  • Normal birth (no forceps, vacuum or caesarean): 90%
  • Caesarean 5%
  • Vacuum 3%
  • Forceps 2%

I feel it is important to compare the measurable benefits of private midwifery care against the statistics for the State as a whole.  These statistics are taken from The NSW Mothers & Babies Report 2010 which are the latest statistics available.

Private midwifery care can increase the chance of a normal birth

  • In NSW, only 58% women birth their babies normally.
  • This rate increases to 89% through this service

Private midwifery care can reduce the need for an epidural

  • 47% of all women used an epidural in labour.  This commonly leads to an assisted delivery, possibly with an episiotomy.
  • The epidural rate is a mere 5% through this service

Private midwifery care can increase a woman’s chance of having a drug-free birth

  • NSW-wide, only 10% women birth their babies drug-free.  90% women use some form of analgesia.
  • Through this service, 82% women use no medical form of pain relief for labour.

Private midwifery care can reduce the need for a caesarean

  • 30% of women in NSW had a caesarean in 2010.
  • 5% women require a caesarean through this service.

26% of first time mothers had caesareans in NSW compared to only 5% of women who chose private midwifery care.

Private midwifery care increase the chance of a successful VBAC

  • In NSW in 2010, only 12% of women who had had a previous caesarean achieved a vaginal birth
  • This increases to 88% when women choose this service

Private midwifery care can increase the chance of  homebirth

  • Only 0.3% babies are born at home in NSW
  • 49% babies are born at home through this service

Choosing a private midwife more than doubles your chance of starting labour without medications

Choosing a private midwife trebles your chance of needing no stitches after birth

Private midwifery care reduces your chance of an episiotomy by 83%

Learn more about private midwifery care and antenatal shared care

Re: Challenges of private midwifery

A midwife colleague of mine in QLD, Barbara Cook of Serene Births, has recently experienced a challenging time with a client.  This was a situation where she offered to support a planned hospital birth, rather than a planned homebirth for a woman when her care needs escalated, and the midwife's attendance at a homebirth would not meet the standard of care that private midwives offer in Australia.  The client had had a previous caesarean section, and she had found this to be a traumatic event.  In the last paragraph of her blog post, Barbara comments,

“Yet if this woman had been supported well in her first birth with a known midwife she may not have required the caesarean, she now would be in control of her destiny and probably be able to birth at home.”

This is something I wanted to draw on: the choices that women make – sometimes knowingly, but most often unknowingly – in their first pregnancies, and the far-reaching impact that this has on future births.

Many women have a “see how it goes” attitude to their first births, perhaps not realising how important a first birth is in terms of bonding, breastfeeding, attachment, how a woman feels about herself, how she reflects on her birth in years to come, and the choices she makes in subsequent births.

In my practice, I meet a large number of women who feel traumatised by their first births, and I work with them as they journey through their second pregnancies.  The path is usually not smooth, and there are many bumps along the way: fear, uncertainty, doubt, anxiety, tension, sadness, grief, guilt – a whole gamut of emotions.  It is necessary to unpack and process all of these emotions before we can plan for a positive birth.

When women are supported well in their first births with a private midwife, they are highly unlikely to require a caesarean, and they tend to reflect on their births as a wonderful, positive experience.  Whatever comes up in their next pregnancy, they know they can do it (they have done it before), they are considered low risk (previous normal birth is the most likely outcome with a private midwife), and all the care options are available to that woman.  A previous caesarean means that a woman may be viewed as high risk for all of her subsequent pregnancies, with all of the emotional trauma that often accompanies an emergency caesarean when a woman was planning to “see how it goes”, thinking, “it’ll never happen to me”.

Learn more about private midwifery care and antenatal shared care

Which birth choice is right for me?

In the blog post below, I am going to go through a few scenarios or preferences, and suggest a care option that may best suit that woman. I am going to choose from only four options, even though there are many many different models of care for pregnancy and birth.  The options I am going to choose from are:

Private midwifery care either for a planned homebirth or a planned hospital birth

This is a continuity of carer model whereby a woman is cared for by one midwife from early pregnancy through to birth and the postnatal period until the baby is 6 weeks old.  Where the woman has complications in pregnancy or requires a higher level of care, the midwife is able to refer the woman directly to an obstetrician, or the baby to a paediatrician.  The midwife is also able to order all the necessary tests and scans for the woman.

Private obstetric care for a planned hospital birth

This is a continuity of care model where the woman's pregnancy care is provided by one obstetrician.  The labour is attended by hospital midwives who are not known to the woman before labour starts, and the birth is attended by the obstetrician with whom the woman has a relationship.  The postnatal care is provided by hospital midwives who are not known to the woman, and the obstetrician provides a final check at 6 weeks postnatal.  This model of care is available in public and private hospitals.

Shared care: either with a GP or a private midwife

This is where a woman attends a private midwife or her GP through her pregnancy (continuity of carer for pregnancy), however the birth is attended by the hospital midwives and obstetricians at the hospital at which the woman is booked, as a public patient.  Once the woman is discharged from hospital, she may again be cared for by her private midwife or GP.  This is a model of care within the public system, where some of the care (ie, the pregnancy care) is provided by a private practitioner.

Standard public hospital care

In this model, a woman is cared for entirely by the public hospital staff.  Generally the woman attends the antenatal clinic for her pregnancy care, where she is seen by the midwives who are on duty that day.  From one visit to the next, the woman may be seen by different midwives.  Some hospitals have a midwife clinic where it is possible for the woman to be seen by the same midwife for most of her pregnancy (antenatal) appointments.  In labour, the woman is cared for by the midwives and obstetricians who are on duty.  These midwives and obstetricians will not be known to the woman ahead of time, and they work in shifts.  Once the baby is born, the woman moves to the postnatal ward where she is again cared for by midwives she has not met before, who work in shifts. This model of care is absolutely free to Medicare card holders, and in Australia, our public system delivers a very safe standard of care.

I want to build a relationship with the midwife who will be caring for me during birth.

This woman would be best to choose private midwifery care. This is the only model where all of your care is provided by one midwife.

I want to feel prepared, informed and confident as I approach my birth.

This woman would best be cared for with private midwifery care, or with private midwifery shared care.  In both models, midwives work very closely with women, through education, preparation, support and lots of time for questions and discussion.

I want basic care: just a quick check and basic education to be safe.

This woman could be cared for with private obstetric care, GP shared care or public hospital care.  It might be best suited to a woman who has had a normal, straightforward birth before, who just wants the basics to be safe.

I want to build a firm relationship with the obstetrician who will be present if something goes wrong.

Private obstetric care might be best here, however there are models of collaborative private midwifery / private obstetric care that might also be helpful.

I am planning an elective caesarean.

Probably private obstetric care will be best.  You will get to know your obstetrician well during your pregnancy, and s/he will attend your caesarean.  This is very reassuring care for women planning a caesarean.

I want to have home visits from my midwife after my baby is born.

Private midwifery care would be best.

I am planning a waterbirth / home birth

Private midwifery care again.  Public hospitals generally don't provide homebirth services, and waterbirth rates can be quite low.  Private midwives have the highest rates of homebirth and water birth.

I am planning a VBAC

Private midwifery care will give you the best chance of a VBAC (vaginal birth following a previous caesarean).

 Learn more about private midwifery care and antenatal shared care