Information to make Informed Maternity Care Choices.
After forty-one years of midwifery practice, the last 8 in New Zealand where many acknowledge that maternity care is in crisis, I have created a petition that respectfully requests that the New Zealand Ministry of Health:
- Develops an accessible, practical campaign to promote, support and protect natural or physiological birth throughout New Zealand.
- Widely publishes data on all New Zealand place of birth outcomes to foster informed maternity choices.
- Provides dedicated funding to ensure equitable access for well women to local community oriented, physiologically appropriate and culturally sensitive primary birthing units.
- Publicly promotes, encourages and supports birth at home with experienced midwife for well women.
- Engages with women, their whanau and national media as well as representatives of all maternity care providers toward achieving the aforementioned goals.
1) Normal Labour and Birth.
Only one-third (33.2% or 19,646) of birthing women in 2014 had a normal birth according to the Ministry of Health’s (MOH) annual report. This was the first time a definition, and any information about those who have “a spontaneous vaginal birth without an induction, augmentation, epidural or episiotomy”; have been included in these reports. Rates varied according to maternal age, socioeconomic status, ethnicity, location and whether it was a first or subsequent birth. For example, as in other parts of the world the more well-to-do women had fewer ‘normal’ births than their more deprived sisters and women in some rural regions,
An understanding of the rates, impacts and influences on ‘normal’ birth, are important in assessing the quality of a service, and accounting for the cost of that service. Normal labour and birth consumes less of a nation’s health resources, personnel, equipment and hospital beds.
Mothers who experience ‘normal’ birth are more likely to feel positively about their labour and birth, to bond more easily with their newborn, and to have less difficulty establishing breastfeeding. Thus birth and its consequences can provide psychological, as well as physical benefits for the woman, her baby, whanau and community. However, local surveys, articles and international studies reveal that for many women birth is traumatic and there is a lack of funded support services for these women. In addition, suicide is the leading cause of maternal death in NZ, and other countries, therefore maternity service providers need to consider the potential psychological as well as physical impacts of their policies and the information they offer women.
As, UK Professor Soo Downe says; “Most women, in every country across the world, would prefer to give birth as physiologically as possible. For most women and babies, this is also the safest way to give birth, and to be born, wherever the birth setting. If routine interventions are eliminated for healthy women and babies, resources will be freed up for the extra staff, treatments and interventions that are needed when a laboring woman and her baby actually need help. This will ensure optimal outcomes for all women and babies, and sustainable maternity care provision overall”.
Thus, in addition to meaningful definitions, the UK, Canada and other places have campaigns to improve rates of ‘Normal Birth’, and programmes to lower interventions, such as surgical deliveries. The UK “Campaign for Normal Birth” is a practical, accessible and evidence based effort, developed and supported by a broad range of maternity professional and user organisations including the Royal College of Midwives, Royal College of Obstetricians and Gynaecologists (RCOG) and the National Childbirth Trust. It has now morphed into the Better Births campaign.
New knowledge about our Microbiome, its development, and Epigenetics show that we are yet to learn the full implications, and costs of interventions in labour. Though rising each year, the levels in New Zealand are on the lower side of the middle range for most interventions in comparable countries.
2) Impacts of Hospital Birthing.
Currently, the majority of NZ women labour and deliver in hospitals; 87% in 2014, despite extensive research on the adverse impacts of hospital settings, procedures and staff on natural labour and birth. Medical interventions are often unrelated to the health status of the woman. Also, the rates of most childbirth interventions are happening at ever increasing rates each year, for example 25.9% of all births in 2014 ended in a Caesarean section, up from 23.3% in 2003.
The UK Birthplace Study shows that natural, satisfying birth is most likely to happen at home or in a free-standing birth centre or primary unit. NZ research on birth outcomes, confirms that this is also true here. There is a lot of evidence which shows that where a woman labours and births has a dramatic effect on intervention levels such as induction of labour , , , . Evidence also indicates that when healthy women labour and birth in hospitals, compared to being at home or in a primary birthing unit, they have increased rates of interventions, even when they have continuity of carer , .
Though the levels of childbirth interventions are universally higher in hospitals, the perinatal or ‘around birth‘ mortality or death rates, are similar for low risk women at home or in a birth centre , . Likewise being born in a hospital, rather than a birth centre does not necessarily improve mortality outcomes for babies. Internationally, as well as in NZ, healthy or low risk women report higher satisfaction with their birth experience in “home‐like” environments, compared to those who labour in hospital settings .
The July 2011 Expert Advisory Group report of the RCOG said; “Too much care is provided within secondary and tertiary settings. Too many babies are born in the traditional ‘hospital’ setting. We need to drive this care back into the community with the appropriate provision of facilities and professionals with appropriate skills.”
The majority of women in New Zealand, 93.7% in 2014, were cared for by a midwife Lead Maternity Carer (LMC). Also in 2014, 87% of all births occurred in hospitals where interventions happen, even in the births of healthy first time mothers. These facts suggest that many midwives need to re-learn the knowledge and skills involved in supporting out of hospital birth. A maternity system that promotes primary birth options and normal outcomes would increase midwifery satisfaction and retention rates, as well as improve the wellbeing of women and their whanau.
Also, in the UK there is a website to inform women of the outcomes for each birthing unit across the nation. Although there is no NZ equivalent, a post-graduate midwife is creating an ‘App’ for women about the outcomes of birth places here. A study in Iceland shows that “Efforts to de-stigmatise out-of-hospital birth and de-medicalize women‘s attitudes towards birth” increase women׳s use of health-appropriate birth services.
2.1) Primary Birthing Units (Birth Centres).
Recently,the National Institute of Clinical Excellence (NICE) said that midwife-led care has been shown to be safer for women and recommends that all women with low-risk pregnancies should be advised that giving birth in a midwifery-led unit, is “particularly suitable”. Here in Aotearoa, studies have also found improved outcomes for mothers and babies when a woman labours in a primary unit, compared to similar women who use a hospital.
Increased understanding of the impact of environmental factors on labour and birth, confirms the findings of UK surveys of women about factors which aid or hinder labour progress. These elements have been incorporated into the Mind-Body-Spirit Architecture of Bianca Lepori to create spaces which best support physiological labour and birth . This knowledge has been used to develop the Birthing Unit Design Guideline, which is being applied in the rebuilding or refurbishment of many maternity units throughout Australia.
Studies show that Birth Centres (or Primary Units) can:
- address social exclusion by creating an open, flexible and accessible non-judgmental approach to care.
- build communities by forging links with parallel agencies.
- enhance recruitment and retention of midwives through increased job satisfaction.,
- encourage partnership and multidisciplinary efforts by working in the community .
Creating local birth units which are appropriately designed, community oriented, family-friendly and culturally sensitive across NZ would achieve all of the above, as well as be consistent with government programmes such as Whanau Ora and integrated health centres. However, development of such birthing units in Wellington, Dunedin, Palmerston North and Waitemata has not happened, despite various campaigns. A private company who recently opened a ‘birth centre’ in Bethlehem is building others in Palmerston North and Melling (Lower Hutt). Sadly these units appear to lack community consultations and connections.
Meanwhile, in other parts of the country, many older, community-based primary units are under-utilised, as women travel further to be delivered in hospitals, believing this is their ‘safest’ choice. Sadly, low occupancy has resulted in closure for some of these units, despite public campaigns to keep them open, as DHBs yield to short-term financial constraints. Hawke’s Bay hospital now has a new primary unit in the grounds of their hospital, in place of another older, remote one. However, evidence shows that units alongside obstetric facilities have higher transfer rates and therefore more interventionist outcomes compared to stand alone or free-standing birth units.
Thus, some DHBs inadvertently encourage all women to deliver in hospitals, such as in Waikato where a reduction in local birthing units is happening whilst Hamilton will lose 22 under-paid LMC midwives before next year. NZ midwifery is suffering with increased demands on all but particularly on low paid, poorly resourced, under-appreciated and sadly many unsustainable LMC practices.
In the UK, there are campaigns by the national health services and parliaments of UK countries to increase homebirth rates, including as part of local health strategies. The RCOG publicly supports homebirth, stating: “The review of the diverse evidence available on homebirth practice and service provision demonstrates that home birth is a safe option for many women.”
Similarly in Canada, medical groups acknowledge the growing evidence showing homebirth with a midwife is a valid birth option for well women . A recent West Australian government review confirmed there is “no evidence of adverse outcomes associated with planned home birth in low risk pregnancy”.
Here, in NZ, homebirth rates have been around 3% for the last decade, involving mostly older women, Maori and European, as well as some in rural areas. Home Birth Aotearoa has gained government funding to share their knowledge and experiences about the safety and benefits of birthing at home with a known, experienced midwife. Still support for homebirth midwives from DHBs is variable, often minimal and usually involves a fee. Other than an infrequent statement there is no obvious MOH or DHB supports or promotions, although studies are showing that homebirth is safer than hospital. Research shows that home is where natural birth is most likely to happen, leaving mother, baby and family in optimal psychological and physical health, thus homebirth is where health dollars and resources can be saved in the short and longer term. A 2012 Cochrane Review concluded that, “all countries should consider establishing proper home birth services. They should also provide low-risk pregnant women with information enabling them to make an informed choice.”
In recent decades, knowledge, understanding and experiences about physiological or truly natural birth have revealed how labour hormones work when a healthy woman in a nurturing and supportive environment is disturbed as little as possible. Ongoing respectful, quiet support of skin-to-skin contact, and possibly the first breastfeed, enables placental separation and birth, as well as minimising maternal blood loss, because undisturbed hormones peak after birth of the baby. Not clamping the umbilical cord before it has stopped pulsating, gives the baby back all its blood volume and nutrients, assisting its transition to extra-uterine life and optimal development.
Sadly, most NZ doctors, other health professionals, managers and many midwives have only experienced disturbed, managed, fraught hospital deliveries and so, like most of the population have some fear of natural childbirth, or Tocophobia in its extreme form. In the UK, Tocophobia is recognised as a contributor to and consequence of our birthing culture, so it has informed new maternity policies and campaigns there.
Finally though there is some internet leakage of positivestories on homebirth and midwives from UK news sources, this is not generally the direction of NZ based maternity news reports. Overall there is a complementary need for the NZ government to redress the national under-valuing of midwives and unbalanced media which contributes to a lack of trust in normal birth and midwives, and perpetuates the myth that hospital is always safer.
As UK Midwife Sheena Byrom in her most recent blog titled ‘Normal Birth – a moral and ethical imperative’ said “Promoting normal birth while also maximising the wellbeing of mother and baby is therefore not a cult, or a professional project, or a conspiracy. It is a moral and ethical imperative, that should be supported by all of those with any interest in the wellbeing of mothers, babies and families, in the short and longer term. This includes professionals, journalists, politicians, health service managers, childbirth activists, and lawyers”
 Solomon, J. ‘New Zealand Research on Place of Birth’, Women’s Health Update, Vol 12, No 1, January, pp. 1 ‐ 2.
 Earl, D. Hunter, M. 2006 ‘Keeping birth normal: midwives experiences in a tertiary obstetric setting’, New Zealand College of Midwives Journal, Vol 34, April, pp. 21 – 23;
 Hodnett, ED. Downe, S. Edwards, N. Walsh, D. ‘Home‐like versus conventional institutional settings for birth.‘ Cochrane Database of Systematic Reviews 2005, Issue 1, Art. No: CD000012. DOI 10.1002/14651858.CD000012.pub2.
 Skinner, J. Lennox, S. 2006 ‘Promoting normal birth: a case for birth centres’, New Zealand College of Midwives Journal, Vol 34, April, pp. 15 – 18.
 Davis, D., Baddock, S., Pairman, S., Hunter, M., Benn, C., Wilson, D., Dixon, L. and Herbison, P. ‘Planned Place of Birth in New Zealand: Does it Affect Mode of Birth and Intervention Rates Among Low-Risk Women?’ Birth, no. 10: 1523-536.
 Miller, S. 2009 ‘Are midwives more ‘at home’ at home?’, Birthspirit Midwifery Journal, Issue 1, February pp. 7 – 11.
 Olsen, O. 1997 ‘Meta‐analysis of the safety of home birth’. Birth, Vol 24, No 1, pp. 4 – 13.
 Olsen, O. Jewell, MD. 2000 ‘Home versus hospital birth’, Cochrane Review. In: the Cochrane Library, Issue 2, 2000. Oxford: Update Software.
 Smythe, L. Payner, D. 2008 ‘Warkworth Birthing Centre: an appreciative inquiry’, AUT University.
 Earl D, & Hunter, M. (2006). ‘Keeping birth normal: midwives experience in a Tertiary obstetric setting.‘ New Zealand College of Midwives Journal 34,21-23.
 Fahy, K., Foureur, M. & Hastie, C. (2008). “Birth Territory and Midwifery Guardianship. Theory for practice, education and research.” Books for Midwives Elsevier.
 Kirkham, M. (2003) ’Birth Centres; A social model for maternity care.’ Books for Midwives, UK.
 de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B, Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S. ‘Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births.‘ BJOG 2009.