If you truly desire to engage in birth proactively, and are hoping to have an undisturbed physiological birth, because you acknowledge the importance of the passage of birth for you and your baby to consciously cross as a team, undrugged and undisturbed, then choosing your care provider may be one of the single most critical things you can make a decision about.
The research in the Cochrane database indicates that women do best to have a physiological birth when they are attended by one, or more, experienced care providers whom they have known continuously throughout labour. This is called ‘continuous care’ or continuity of care.
By definition ‘continuity of care’ means you have built rapport, established trust and a warm connection with an experienced care provider during the antenatal visits and period leading up to birth. It also means you, and your care provider share the same philosophies about birth and are on the same page.
Note the key words here, experienced and continuously.
This makes perfect sense, doesn’t it? Of course you want someone you know and trust (with your life, and your baby’s) to support you through this momentous, life changing event.
The reality in most birth settings and places in Australia is that the system/s we have are not designed, or resourced, to honour this very important factor.
Midwives often work in teams and you may see someone different each time you have an antenatal visit, hospital care providers change shifts, strangers may come in, the structure is hierarchical, not collaborative. Your care provider may be ‘with’ you and 3 other women birthing at the same time. This does not properly fulfill the criteria of ‘continuous’ care.
The necessary elements of continuity of care and the benefits it confers are not always readily available, with some exceptions. This means you have to be the one to design your own birth team and support if you really want to uphold this factor of continuous care. Unfortunately, independent midwives in Australia are few and far between, and not always available depending on your location, and they may not be accessible to you for affordability reasons. Also, independent midwives are generally (there’s some exceptions in certain hospitals) not permitted to accompany women as a professional care provider in hospitals in Australia, even though they are registered to practice, they practice outside of the system for women choosing home birth (separate to a publicly funded home birth).
The statistics reflect this, in Australia less than 0.3% of women birth at home. So chances are, you’re planning to birth in a hospital or a birth centre. And chances are, that facility may not be able to bestow you with the gift of continuous care in the truest sense of the word.
Then there’s something else to be mindful of…
The (power) dynamic between you and your care provider
There’s another incredibly important thing I feel compelled to add here about a more subtle dynamic of your relationship with your care provider.
You are equals.
There shouldn’t be a relationship of power or authority, but the reality of the dynamic with care being received from an institution is that there IS an inherent imbalance.
You should be encouraged to understand and carefully consider the choices you’ll need to make throughout the antenatal period and during birth, and you should be provided with unbiased information to do this. Your care provider should support you to autonomously make choices without a hidden agenda or bias towards hospital policy or personal preference. When you’ve made your decisions your care provider should accept your position and honour it without judgement. In this type of balanced relationship, you are supported to make, and own your choices based on real facts and statistics versus being offered information that is designed to persuade you to make decisions based on hospital policy and perceived risk (in contrast to ‘real’ risk).
If this dynamic is imbalanced, then your care provider is in a position of authority and you become a patient to be managed and elicit compliance from. This power imbalance can be a little harder to discern so requires careful attention to the way your care provider delivers information to you and what the information is, how they respond and so on. Or it could be really obvious. For example, when a care provider disallows a birth plan or your reasonable birth intentions this is cause for concern.
What to do then?
Some women will perhaps grapple with this and assume that they would be best to seek out a care provider in a private hospital. Surely this will guarantee continuity of care, come with the benefit of familiarity and trust that accompanies such care, and therefore improve your chances of physiological birth? Not necessarily.
In the private setting, your primary relationship is with a private obstetrician. These doctors are trained and highly skilled in caesareans, surgery, medical surveillance and implementing tight timing protocols and interventions that generally disrupt a physiological birth process. The busy obstetric doctor is not going to be the person breathing with you during contractions or encouraging you, tending to your emotional needs and bolstering you and your natural resources to achieve a physiological birth. This is the role of a midwife (if she has the time – depending on how well resourced the hospital or birth centre is), or a doula, or both.
If you choose a private obstetrician, you’re choosing to pay big money for a doctor who has received their training in complications relating to pregnancy and birth. Unless you have some type of inherent risk, or a medical condition, this can be a riskier choice of care provider, especially if you’re a woman wanting an undisturbed birth. In the private sector, generally c-section rates and intervention rates are higher. You can find out the statistics of the care provider with some hunting. You should be able to ask directly. Any kind of ignorance, avoidance or disregard for your request for such information from the doctor might raise a few warning bells.
To use an analogy, it’s a little like taking your pet to the vet when they’re perfectly well and in good health. What might happen? The vet will look for something – a problem – to fix – and probably will find something because they’re looking. For most women, pregnancy is normal and low risk and there isn’t a problem that needs to be fixed, you simply need to be allowed the time and space to birth your baby in a way that supports physiological birth. “If it ain’t broke, don’t fix it!”.
Which brings me to another animal analogy. Think about how a cat gives birth to kittens. She finds a dark, sheltered, warm and private space where she won’t be interrupted. Because of the safety of her environment, the cat is able to relax and give birth. As humans, we need the same conditions, with one additional thing, the right support from another human being.
Ideally, research suggests that for normal physiological birthing this support comes from a skilled birth companion, primarily a midwife, with whom you form a relationship with over the pregnancy, birth and into the fourth trimester (the early postpartum period).
In reality, many women will not have the option of a true ‘one on one’ continuity of care model available to them, so we circle back to the suggestion of designing your own birth team.
The best approach?
Find the closest thing to one-on-one known, constant, reliable continuous care with someone (a midwife or doctor) you trust and opt for it, do the best with what is accessible and available to you. Interview different care providers, research your options, ask friends and strangers and investigate the behind the scenes statistics from the hospital and/or midwife or doctor you’re considering. And remember with private care, just because you’re paying (a lot) for it doesn’t mean it’s better or more aligned with your birth wishes, you will have to do the research to determine that.
In some hospitals in Australia women do have access to Midwifery Group Practice*, where you can be assigned one midwife from the beginning to end of your pregnancy, and that midwife is on call for your birth. Ask whether this is available and if so, whether it is 1:1 care, or something else, such as a small team of midwives. Ask around to find out if this type of care is available where you live, phone the hospital, birth centre etc, and speak to someone. Don’t take your GP’s advice, or someone else’s word as gospel, they may not know.
You may also consider doula support to supplement your care for birth and to fill in the gaps where continuous care is not being fully met by your chosen care provider. Remembering that a doula is a non-medical birth support person. A doula is most likely to be that person bolstering your morale, your natural coping mechanisms and generally encouraging and holding space for you to birth in alignment with your wishes as well as supporting your partner if needed.
The impressive benefits of doula support for women was recently confirmed by the 2017 Cochrane Review on the Continuous Support for Women during Childbirth.
This study considered the difference in benefit to the woman with support from a doula, versus hospital staff, versus members of the woman’s social network. In the study, ‘doula’ was defined as someone who is neither a member of the hospital staff nor a member of the woman’s social network, and is present only to provide labor support.
Among the three types of providers of continuous support, someone in a doula role appears to offer the greatest set of benefits to laboring women. In comparison with women receiving no continuous labor support, women with doula role support were an impressive:
+ 39 percent less likely to have a cesarean birth
+ 35 percent less likely to have a negative birth experience
+ 15 percent more likely to have a spontaneous vaginal birth
The review also found women who used a doula had a reduced use of synthetic oxytocin, any pain medication while giving birth, and lower rates of newborn admission to a special care nursery.
I know you’re a woman who understands that birth matters and you want to do all you can to ensure your birth is positive. I hope that this information helps you to see why taking a considered and researched approach to choosing your care provider is important. To give yourself the best chance of having a physiological birth, finding the right care provider for you who offers continuity of care, or as close as possible, is really fundamental.
*Here is an unconfirmed list of places where Midwifery Group Practice may be available. NB: This list is a guide. This list is not exhaustive or complete, and it is not updated on this site. You’ll need to check with your local hospital or birth centre to confirm whether the practice in your area actually offers true 1:1 continuous care, or a version of it.
Royals Women’s Randwick
Gold Coast university Hospital
King Edward Perth
Royal Prince Alfred (Sydney)
Crystal Brook (SA)
Mossman (far north qld)
Darwin has a home birth service which offers women the same single midwife parentally and at birth.
Clancy Allen is a Certified Doula, Kinesiologist & Yoga teacher specialising in pre-natal yoga. Clancy provides birthing services around Newcastle & the Central Coast, NSW. Clancy is passionate about birth being experienced as a rite of passage where women experience and know their power.