My Midwives
Over the previous months we have run through a few of the decisions about preconception, and when you find out you are pregnant. This month we will focus on the next key decision – which is choosing your care provider.
It is fortunate that in many areas of Australia women are spoilt for choices but often don’t know what they need to know in order to make a choice of care provider and or place of birth. In other areas, particularly in regional and rural areas women are often not so lucky and may have one option. In remote areas women may have no options at all and may have to travel, sometimes long distances, to receive maternity care.
Model of care available
Broadly it is worth considering a few things at the beginning. Are you wanting to have the same care provider for all your pregnancy care, so that you know them when you are in labour? If the answer is yes, then it is also worth considering what type of birth you are seeking and whether or not you have private health insurance.
Continuity of care is where the same health professional provides care from early in pregnancy through labour and birth and often into the post birth period. The carer can be an obstetrician or a midwife. In the private sector you can have either a private obstetrician, who may work with a midwife, or a private midwife, who will generally either be working with private obstetricians or may work with a GP or public hospital.
Private obstetrics – pro’s and con’s
There is little doubt that most people view private obstetrics as the highest standard in care. However, there is not a large amount of evidence to outline the outcomes for women and babies in this model. You have the same obstetrician providing all your antenatal care, which is subsidized by Medicare. The obstetrician may have a midwife (or may share care with another obstetrician or group of obstetricians) for times where they are not available. Generally, the obstetrician will work in a private hospital and the private hospital midwives will admit you when you arrive in labour with your obstetrician coming to review you at key decision-making points during your labour and for birth. The private hospital midwives provide the remainder of the care. Your obstetrician may have specific policies that they use for all women, for example they may require you to be monitored continuously with external fetal leads, they may want you to have an internal fetal monitor once in labour, they may require you to birth your baby in certain positions and they may, or may not, support different forms of pain relief such as water immersion and water birth. It is really important to find out what your obstetrician supports in labour before you are too far along in pregnancy. The pro’s are having the same doctors available (or small group of doctors if your obstetrician works this way) and having a care provider that can perform a caesarean section or operative birth if needed. The con’s are that evidence tends to show that private obstetricians have higher rates of intervention in birth and that it is the midwife who provides most of your labour care and you do not know her. Additionally, once discharged from hospital, your obstetrician may only see you at 4 or 6 weeks after birth.
Private midwifery – pro’s and con’s
Private midwifery is possibly the hardest model to access but there is possibly the highest level of research about this model. Women and babies have great outcomes with 18% higher rates of spontaneous vaginal birth, 16% lower odds of caesarean section, 24% reduction of preterm birth, 15% higher odds of breastfeeding and 9 % higher odds of breastfeeding continuation as well as 43% lower odds of readmission to hospital within 30 days of birth compared to women who receive standard care (source: Cochrane review, 2016).
You generally have the same midwife providing all your antenatal, labour and birth and post birth care which is subsidized or subsidized in part, by Medicare. The midwife may work in a small group of midwives and may have a partner midwife who provides “back up” when the midwife is not available. They also need to have an obstetrician or other medical provider to consult and refer to if there are complexities in the pregnancy. Generally, your private midwife will see you in early labour at home and may then make recommendations about when is a good time to go to hospital. Private midwives also may provide birth care at home. If your private midwife has admitting rights, she will admit you to hospital and continue your care. Most private midwives offer a range of options including water immersion and water birth. They will usually discuss with you all the alternatives available and will have provided you with an opportunity to express the choices that you think you may like to make. They will continue to provide you with options along the way including increasing your choices around pain relief and decisions about different positions for birth. The pro’s are that private midwives are often able to provide different options for care, and that the same person will provide your care throughout the whole continuum including the post birth period, the con’s are that midwives are not able to perform caesarean and/or forceps births. They also generally cannot provide admitted birth care in private hospitals and this limits the place of birth to public hospitals, birth centes and home birth.
Midwifery Group Practice
Midwifery Group Practice is a hospital-based group of midwives who offer individualised, woman-centred care with your own midwife throughout your pregnancy. They or their partner midwives will be on call for your labour and birth and will provide follow-up visits generally at home with your baby. The midwives work with a small group of other midwives and if you are accepted into the MGP for your pregnancy care, you will get to meet the other midwives in the MGP during your pregnancy.
The pros of MGP are that it is free as it is part of the public health system, a continuity of care model, they have access to the hospitals other resources such as Lactation Consultant service and doctors etc. The Cons of MGP are that they have limited spaces available and fill up extremely fast, women often find it hard to get into a MGP. You generally need a GP referral to the hospital (but every hospital is different).
Shared care
Shared care is an option for women where they have a regular GP, and that GP provides some maternity care in conjunction with the public hospital antenatal clinic and public hospital labour and birth suite. The main disadvantage is that whilst you know your GP, you will not know the midwives or obstetricians providing your birth care. You may also be restricted by hospital policy and what is available in terms of water immersion and waterbirth and the place where you will birth. The pro’s are that this model is readily available in most public hospitals and that there is no cost.
Standard hospital-based care
There is no continuity in this model at all. You will see whoever is available within the hospital including midwives, doctors and training doctors. The pro’s are that this model is available in nearly all hospitals and therefore it does provide an option for a large number of women and families. The cons are that there is no research that demonstrates the efficacy and outcomes of this model and what it can do. Again, you may have some choices available but not others such as water immersion and then nothing.
Rural and remote maternity care
When living outside of urban centres and not close to regional hospitals, care may be limited. There may be a GP who can provide some of your care or a primary care clinic where a midwife may be available. In this situation it is worth doing what is suggested below to increase your options.
Where you just don’t know what you want to do
At the beginning of pregnancy, it is best to plan for a broad options as you can find and afford. Evidence demonstrates that the highest levels of satisfaction are found in continuity of care models so seeking one out where you have access to midwifery care for the parts where you need midwifery care and obstetric care for the parts where you may need it is an excellent first step. For those with private health insurance examine what is possible in your closest private hospital and review what is available locally in terms of different options. If you are not sure of what you want in terms of things such as pain relief and water birth, find a hospital that supports as many choices as possible so that you are not ruling them out based on the hospital. Consider finances – ask about payment plans, what is rebated by Medicare and what is rebated via public health and then if you need to fill in gaps in what you want you can also try and seek this during pregnancy. For example, if you have a private obstetrician but don’t know the midwives maybe having a doula for additional support or maybe hiring a private midwife for after birth. Or if you have a private midwife or midwifery group practice check whether you meet some of the obstetricians they may work with in situations where this may be needed (operative birth) and check out where they are able to provide your care.
Finally, as everyone does similar things – book as early as possible! Many midwives and MGP’s are popular and are booked out by the end of the 10th week or so.
