Exploring where to birth my baby.

After we find out we are pregnant, one of the first major decisions we have to start making is where we will give birth and what form of perinatal and postnatal health care we wish to receive. Maybe we already gave this some consideration before we conceived. Regardless of when we start exploring our options ~ this is one of the most significant decisions women and birthing people make during their reproductive journey.

Who cares for you matters, where you give birth matters. These decisions should be influenced by how you would like to give birth - are you aiming for a low-intervention, physiological birth? Are you wanting access to an epidural or narcotic pain relief? 

Likewise, it’s worthwhile exploring your assumptions and beliefs around birth and pain whilst making these decisions. Do you fear the pain of childbirth and think it is something to be avoided with modern interventions? Do you view birth as a (in most cases) normal physiological event or is it something pathological that requires medical care? What is informing your desire to birth somewhere with certain carers and what are you avoiding by ignoring other options? 

Birth unfolds best when a person feels safe, comfortable and is able to fully surrender into the neurobiological and hormonal process of labour. Consider how you feel in different environments when making your decision on birthing location. Of course, birth is a wild mystery and location can shift, but making informed choices and having an understanding of the different spaces you may find yourself birthing in is important to the overall experience. 

Not all places support physiological birth equally, as demonstrated in the data. If you are wanting a low intervention, physiological birth, the evidence shows that in Australia, you are twice as likely to have a normal birth in a midwifery led birthing centre over the hospital system and 6x as likely to have a physiological birth at home with a private midwife. Highest rates of interventions occur in private hospital care. 

copyright Mara Berendt Friedman

So what are our options for birth location and care providers?

In Australia we can give birth in the public hospital system, the private hospital system, at home with a midwife or at home without a medical professional present (freebirth). I’m not going to talk about private care or freebirth in this post.

Before we dive into these different options it's important to note that the gold standard for maternal health care is midwifery led and offers continuity of care throughout pregnancy, birth and the postnatal time. The research shows this has the best outcomes for mother, parents and babies.

In the public hospital system women are often cared for within an antenatal clinic by a mixed team of health professionals ~ an obstetrician, midwives, residents and registrars. This form of care is not midwifery led in all hospitals though many in NSW now offer continuity-of-care (CoC) programs such as Midwifery Group Practice (MGP). Within the public hospital system obstetricians hold the most power and can override what midwives advocate or perceive as best practice care for individuals during pregnancy and labour. If you are not eligible for the midwifery program at your local public hospital, care providers who you do not have an existing relationship with may be the ones present during your labour and birth.

Giving birth in the public hospital includes labour in the delivery suite where midwives typically monitor and support most of the labour, whilst OB’s oversee the process and make final decisions if complications arise (of course the birthing woman can decline all interventions). The delivery suites at most hospitals are medical spaces and often don’t cater to supporting the physiological needs of a birthing woman (privacy, dark and quiet), though with support and knowledge your birth team can help make the space feel more cosy, dim and help manage how many people are in the space.

Some statistics to note: 29% of women giving birth in a public hospital will give birth by a caesarean section and 44% of first time mothers will give birth by being induced. Women who have a vaginal birth without intervention tend to have fewer postnatal complications and are more physically able in the short-term to care for their new babies (Rowland and Redshaw 2012).

Most public hospitals also offer midwifery-led clinics (midwives’ clinics), care for relatively normal pregnancies. Health conditions like diabetes or if you are having multiples are expected to receive care from the antenatal clinic. In the midwives’ clinic you usually see the same midwife (or two or three) for all your antenatal checks and appointments. They will do maternal health checks like blood pressure, blood tests and order and review ultrasounds as required. At the Coffs Harbour Health Campus (CHHC aka Coffs Hospital), there is the option to be a part of the Midwifery Group Practice program (MGP). MGP includes antenatal, labour, birth, and postnatal care provided by a known primary midwife within a small team of midwives available 24hours a day, 7 days a week. 

Midwives often also practice in a woman-centered way and will enquire about your mental and emotional wellbeing as well. In midwifery clinics the birth will happen in the hospital's delivery suite. The Coffs Harbour suites have large private rooms equipped with a heated tub for water births and spacious bathrooms. They are still clinical spaces with a strong medical feel to them (compared to the Macksville Birth Centre and home environment). 

However, when funding is suddenly cut for these CoC or MGP programs, women can be left without their familiar midwives and find themselves supported by unknown midwives during their labour. If you’re planning to give birth in a public setting whether in the antenatal clinic or receiving care through the CoC/MGP, hiring a birth doula ensures you have continuity of care, no matter what happens in the hospital system. A Doula can help you make the clinical space feel conducive to physiological birth and advocate for your autonomy and birthing wisdom to be respected.

Doula’s also work independently of the hospital system, so whilst midwives and OB’s have to follow hospital policy, doula’s do not and can support you (non-medically) in ways medical staff are not able to because of the power structures within the institution of their employment. If you’re choosing (or it’s your only option) to give birth in the public hospital system - I can’t emphasise enough the benefits of having a doula by your side.

Birth Centres are also a birthing place option for low risk pregnancies. These centres are often staffed by a team of midwives and are midwifery led, providing complete perinatal, birth and postnatal care for eligible women. “Giving birth in a birth centre results in significantly lower probabilities of intervention” (Yu, et all, 2020). Birth Centres are often a part of a larger public hospital, as in the case of the Macksville Birth Centre, which is located within the Macksville Hospital. Shared care between your obstetrician, GP or private midwife is usually offered.

Macksville also operates under the Midwifery Group Practice model which means that you are allocated a primary caregiver and are typically introduced to the other midwives on the team, so if your primary midwife is unable to be at your labour, you are still looked after by (likely) familiar people. In my experience women will be cared for by their midwife and nurses/other midwives who they have not met before, during their labours. Pregnancy visits are scheduled and blood tests and ultrasounds are required to affirm eligibility for birthing at the center.

Prenatal visits often occur at the centre but your midwife may also do home visits. The birth suites at these centres, and certainly at Macksville, tend to have a homely feel to them. Macksville has beautiful Indigenous birthing art on the walls, timber lining on some of the walls, fairy lights, a big birth pool and spacious shower and bathroom. These spaces are still obviously medical but less clinical than the suites at a hospital.

You are less likely to be induced, have an instrumental delivery, a caesarean section birth, an epidural or use of narcotic pain management because many are simply not provided in this setting and you’ll need to transfer to a hospital where they provide these forms of medical interventions. Birth Centres suit women who are aiming for a physiological birth supported by medically trained midwives in a warmer environment that is woman-centred. Some pain relief is available like gas and water injections.

Homebirth is also an option for many women and birthing people. A private practicing midwife will be your care provider, and offer all pregnancy, labour and postpartum care. Your midwife will visit your home and perform medical tests like blood tests, blood pressure, monitor the growth of your baby/belly and request and interpret ultrasound reports.

In Australia, two registered midwives have to be present during your labour for their insurance purposes. Often you will meet the second midwife during one of your prenatal appointments or you can request this if it’s not the usual practice of your midwife.

If you’re aiming to have a natural, physiological birth and immediate postpartum then a homebirth is your best option. It is an out of pocket cost but Medicare does cover some of it. I am biased towards home birth because in my experience and opinion this is the gentlest way to birth a baby and the environment most conducive to a normal, no intervention, vaginal birth.

Birthing in a familiar environment, with a care team you have built bonds with throughout your pregnancy and under a model of care that centres women and supporting physiology, is truly the best investment for yourself and your baby. And not having to get in a car during labour and contractions! Priceless! In all seriousness though it is a wonderful experience to give birth at home especially if that’s where you feel comfortable, safe and cosy. 

A lot of people hesitate about the cost, but when we consider that the birth experience can have lifelong impacts on families, the thousands (usually around $4000 out of pocket) seem worth it. Many women are moving towards home birth to avoid birth trauma and PTSD which is affecting 33% of birthing women and 6% respectively. In the Coffs region there a few registered homebirth midwives and I recommend Britt Richards.

As the wise elder of birth says - 

 "Whenever and however you intend to give birth, your experience will impact your emotions, your mind, your body, and your spirit for the rest of your life."

~Ina May Gaskin~

References 

Rowland I and Redshaw M (2012) ‘Mode of birth and women’s psychological and physical wellbeing in the postnatal period’, BMC Pregnancy and Childbirth, 12:138, doi:10.1186/1471-2393-12-138.

Yu S, Fiebig DG, Scarf V, Viney R, Dahlen HG, Homer C. Birth models of care and intervention rates: The impact of birth centres. Health Policy. 2020 Dec;124(12):1395-1402. doi: 10.1016/j.healthpol.2020.10.001. Epub 2020 Oct 10. PMID: 33131907.