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Pregnancy Choices – Who do you see?

Pregnancy Choices

Getting pregnant was the easy part – now what?  Who do you see? Where do you go for your care? How do you find out what is available out there and most important of all, what is the best form of care for you.

Joanne said trying find out where to go and who to have care for her was harder than she would have thought. “The GP who did my pregnancy test said, ‘are you privately covered?’ and then he gave me the name of a someone he said was a good obstetrician. I think he might have been a mate from university! It was only after going to the obstetrician and realising I didn’t like his manner and attitude to my questions that I started to ask around. It was then a friend told me about birth centres and midwives and that there were other options. I don’t think it should be like that – there needs to be information out there that women can get hold of. “

When a woman is pregnant for the first time it can be a daunting and confusing process as they try to discover what maternity care options are available and which option will suit them best. The fact that there are an increasing variety of pregnancy and birth options for women to choose from shows how individual this choice is. For some women, however, such as those who live in rural and remote Australia, there may be no choices and only one option. Many women talk to their friends to get information and this can be a great way to get an inside view of what is available but remember it is one view and it is influenced by individual experiences.

Public Hospital Care (75% of births)

Most women who are pregnant, and do not have private health insurance, obtain a referral from their general practitioner (GP) to a public hospital. Depending on where they live, the hospital they choose to attend and their health, they may be able to access several different options.

Midwives Clinics (Medicare card only-no extra costs)

Many major public hospitals have ‘midwives clinics’ which are run by midwives. These clinics are sometimes located in the community and are called ‘outreach clinics’. Midwives are skilled professionals who are qualified to provide complete care for women experiencing normal pregnancy and childbirth and provide continuity of antenatal care for women experiencing normal pregnancies. If any complications develop then the midwives refer women to doctors at the hospital. Women get to know their midwife or midwives during the pregnancy under this model of antenatal care. Women then give birth in the hospital delivery ward and are attended by the midwives and doctors who are on duty at the time. After the birth, midwives on the postnatal ward care them for. Women enjoy seeing the same midwife for their care during pregnancy, as they develop a relationship with them. Midwives focus on more than the physical aspects of the pregnancy. They regard the emotional and psychosocial needs of women as a high priority.

Did you know?

-78% of women in New Zealand have a midwife they know provide all their pregnancy, birth and postnatal care and they have lower caesarean section rates than Australia
-30% of women give birth at home in the Netherlands and midwives provide all the pregnancy care and you only see a doctor if there is a complication. The caesarean section rate in the Netherlands is less than half of ours (14% vs 29.8%)
-In the Scandinavian countries, such as Sweden, midwives deliver most babies and they have the lowest rates of babies dying in the world.

Team Midwifery/Midwifery Group Practice (Medicare card only-no extra cost)

Most women want to receive consistent information and care from someone they get to know throughout the pregnancy, birth and postnatal period. In response to these expressed needs programs like team midwifery and midwifery group practices are increasingly being set up in public hospitals. This involves a small group of midwives that work together to provide antenatal, labour, birth, and postnatal care to women. Many of the larger metropolitan hospitals now run team midwife programs or variations of continuity of care programs. There is now substantial evidence that continuity of midwifery care should be available as a choice for pregnant women. The effectiveness of continuity of midwifery care is largely due to the relationship of trust that is built up during the pregnancy, birth and postnatal period. This form of care results in less intervention and higher long-term breastfeeding rates, as well as lower rates of postnatal depression. Women experiencing this form of care have been shown to feel well prepared for labour, to perceive labour staff as caring, to feel in control during labour and feel well prepared for parenting

General practitioner shared care programs (A cost may be associated)

Most hospitals now offer women the option of having their pregnancy care shared between a general practitioner and a hospital. This provides women with the convenience of accessing their antenatal care in their own local area. They also may have a good relationship with their general practitioner and want to continue this care in their pregnancy. General practitioners participating in shared care programs must meet certain criteria before being able to provide antenatal care. They also will need to refer you to the hospital you will give birth in so you can book in for your care there. You will be asked to return to the hospital for visits with the doctors early in the pregnancy, where they will make sure there are no risk factors in your pregnancy that warrant specialist care. You will then continue to see your general practitioner but you will be asked to return to the hospital for antenatal visits at around 30 weeks, 37 weeks and at around 41 weeks of pregnancy. If you develop any complications you will be asked to see the hospital doctors for specialist care. Hospital midwives and doctors mostly attend the birth and give postnatal care. In some cases, particularly in rural areas, general practitioners may also attend the birth. If your general practitioner does not bulk bill or you do not have a Medicare card you will have to pay for this service. You can arrange general practitioner shared care by contacting your local hospital and finding out if your general practitioner has a shared care arrangement with them or if they run such a program.

Are Birth Centres Safe?

The largest Australian study to date has just been published, looking at the safety of birth centres. Four years of births in Australia (over 1 million women) were examined, of which 21,800 women gave birth in a birth centre. Women were then matched by risk. This means all women giving birth in birth centres and delivery wards, classified as low risk (20-34 years of age, no medical complications during pregnancy), were compared. The rate of babies dying was significantly lower in the birth centre women (both for first time mothers and women having subsequent babies).

Tracy SK, Dahlen H, Caplice S, Laws P, Yueping Alex Wang, Tracy MB, Sullivan E. Birth Centres in Australia: A National Population-Based Study of Perinatal Mortality Associated with Giving Birth in a Birth Centre. Birth 2007;34(3):194-201

Birth Centre Care (no cost for public patients)

Depending on where you live and whether you have any health or pregnancy complications you may be able to choose to have your care through a birth centre. Your general practitioner can refer you directly, or the midwives in the hospital will give you this option when you book in for care. Birth centres are mostly located in hospitals and are staffed and run by midwives with medical back up should complications develop. If you have chosen an obstetrician for your care, ask them if they will attend your birth in a birth centre, as many won’t. Birth centres provide a home like environment where midwives work to care for women through pregnancy, as well as assist them to give birth as actively and naturally as possible. There is a great emphasis in birth centres on empowering women and helping them to feel in control of the whole experience. If there are any complications during the pregnancy or birth then women will be referred to doctors in the hospital. Research exploring women’s birth experiences and outcomes show that women experiencing their care with midwives through a birth centre have lower intervention rates and seem more satisfied than with other forms of care. This is particularly so when midwives work in a team midwifery arrangement in birth centres because women experience even greater continuity of care. Book early though because birth centres are very popular and often over booked.

Private Hospital Care (cost associated) (25% of births)

If you have the appropriate private health insurance (or are uninsured and willing to pay) you can choose a private obstetrician to provide your antenatal care and attend your birth in a private or public hospital. Obstetricians are doctors specialising in pregnancy and childbirth. Check with your health fund to see if you are covered for this care. Costs for private care may not be completely covered by a health fund and you may have to pay part of the fee. There are enormous variations in obstetricians and hospital’s fees so explore this carefully as you may well end up paying out large amounts of money despite being in a private health fund. Choosing an obstetrician can be difficult depending on the kind of care you want. General practitioners tend to recommend a few they know but it may well be as Joanne suspected, because they went to university with them. Friends will give you the inside story on obstetricians but this can be coloured by their own preferences and experiences. It is a good idea to really explore the obstetrician you are thinking of choosing and ask them a series of questions that relate to the type of care and birth you want. For example, if you are after a normal vaginal birth in a birth centre you need to find out up front whether they will allow you to go to the birth centre. Asking obstetricians what their caesarean section rate is, is another good way to discover how interventionist they are. If you want to give birth on a birth stool or in an alternative position other than on your back, ask the obstetrician if they do this as well. You will soon get a feeling of how well the two of you will work together during the pregnancy and birth. It is important that women also realise that private obstetricians usually come to the delivery ward just before the birth – just in time to get the gloves on! Midwives provide all the labour care and communicate on the phone with the obstetrician. If there are any complications or the birth is imminent then they will call the obstetrician. In the postnatal ward midwives will also be the ones to care for you. Research has shown us that if women tend to experience higher intervention rates under private obstetric care. On the other hand women tend to like private obstetric care because they experience that continuity that they regard as so important.

Home Birth Care (cost associated)

Several hundred women each year in Australia choose to give birth at home. Independent midwives care for these women. These midwives work for themselves rather than a hospital. This means a cost is associated with this service ($4000-5000). With the recent maternity reforms private midwives are becoming eligible to provide Medicare rebated care. You need to check if your midwife is Eligible. This means you would get about half the cost back on Medicare. Some private health funds give rebates for midwifery services. The same midwife or small group of midwives provides pregnancy, birth and postnatal care. If you choose this option and complications occur during the pregnancy or birth it may mean you will need to have your baby in hospital. Most midwives will accompany and support you when this occurs and continue to care for you along with the hospital doctors and midwives. Intervention rates in birth are low and women’s satisfaction with care is extremely high when cared for by independent midwives. Currently there are a couple of publicly funded home birth programs run through the hospital system in states such as NSW and Western Australia.

Joanne finally switched to Birth Centre, but because it was later on in her pregnancy she had to wait several weeks until she got into the program. “It was wonderful when a spot became available” she says. “You walk into this cosy place where all the midwives wear normal clothes and you make cups of tea and toast and there is really nothing around to remind you of a big scary hospital. They had big baths where I spent most of my labour. I can truly say I loved having Sam.” Joanne laughs and adds, “I guess I should have a horror story because everyone else seems to, but I just don’t. I gave birth my way and it has made me a stronger person today.” So what advice would Joanne give other women? “Choose wisely. You choose who comes to your 21st birthday party and wedding because you know that adds to the whole experience. You spend months planning it so it’s perfect. You take lots of pictures to remember it and you tell stories about it for years to come. Why should your birth be any different?”

Dr Hannah Dahlen is the Associate Professor of Midwifery at the University of Western Sydney. She has been a midwife for more than 20 years. Hannah is also an executive member of the Australian College of Midwives, NSW Branch. She has researched women's birth experiences at home and in hospital and published extensively in this area. Hannah's website is www.hannahdahlen.com.au

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