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Reducing unnecessary caesareans in midwifery practice

A caesarean section is one of the most common surgical procedures in the world, and while an important life-saving intervention during labour, it is also associated with increased maternal and perinatal morbidity.

Despite this, rates of caesarean sections continue to increase in most countries worldwide. Reducing rates of caesarean sections has long been an ambition of the World Health Organisation (WHO) with a goal of no more than 10 to 15 per cent of births.

Currently, in Australia, the rate stands at 32 per cent, significantly higher than recommended by WHO for births that are high-risk without surgical intervention.

Midwife-led care through pregnancy and childbirth could be key to reducing an increasing number of avoidable caesarean births, according to a new Deakin University study.
Results of the study indicated that, compared with women allocated to usual are, women assigned to midwife-led models of care across pregnancy, labour and birth, and postnatally, were less likely to experience caesarean section, planned caesarean section, and episiotomy.

What is a midwife-led model of care?

A midwife-led model of care is defined as care where the midwife is the lead professional in the planning, organisation and delivery of care given to a woman.

Midwife Kathy Fray said Australian midwives have less autonomy than many of their international counterparts.

"In New Zealand, maternity care is midwife-led, which means midwives are regarded as experts in normal care. This means we know when it's not normal and refer to our obstetric colleagues, but only when there are medical complications.

"Midwifery-led care makes the difference, but the Australian health care system isn't set up that way.

"All pregnant women should see a midwife, who only refers to an obstetrician when complexities occur. It's not dissimilar to seeing the GP for day-to-day and then referring a patient to a specialist," said Ms Fray.

Birth and Postpartum Doula Amanda Bernstein agrees: "I believe that if we had more midwifery based care … throughout pregnancy, birth and into the postpartum, this would improve birth outcomes.

"Not just to reduce rates of caesareans or other interventions, from vaginal exams to continuous monitoring, coached pushing, inductions, but to improve birth outcomes overall.

"We need more access to the continuity of care model with a known midwife, especially for low-risk women who often choose private obstetric care.

"We need greater belief in women and their ability to birth their babies and ways to reduce fear and anxiety around birthing in general."

Debra Wakefield, Midwife and Childbirth and Early Parenting Educator, said the increase in caesarean sections in Australia is complex and multi-factorial, but necessary for the minority of women who experience complications.

"Caesarean births are necessary to save the lives of mothers and babies.

"There will always be a small number of mothers and babies who would die if it wasn't for the option for a caesarean birth."

Some women chose a caesarean birth, which is also acceptable, explained Ms Wakefield, but this should be an educated choice. 

"Some women opt for this mode of birth by choice.

"Birth should be a woman's choice. It is her body, and it is her baby, it is her choice.

"However, she should be fully informed as to the implications of every choice she makes."

Why are rates of caesarean sections increasing?

Ms Wakefield believes many contributing factors lead to increased rates of caesarean sections, including:

• Increasing BMI of Australian mothers
• Altered parameters for diagnosing gestational diabetes, which demands increased surveillance of the pregnancy and often bringing on birth by 39 weeks.
• Advancing age of women birthing in Australia
• The ideal age to give birth is between 18 and 35 years
• Sedentary lifestyle, leading to:
• lack of stamina for labour and birth
• babies who are positioned in a less than optimal alignment to fit out.
• Women telling scary stories about birth, leading to a fear of childbirth.
• Social media and TV shows like "One born every minute" dramatising birth.
• Increased use of "induction of labour" in recent years is possibly the biggest reason for the increase in caesarean rate.
• Social reasons and maternal request.
• Big baby. This is diagnosed on ultrasound, which can be up to 20% inaccurate for estimating "weight" at full term.
• A medical condition of the mother (such as pre-eclampsia).

Reasons that are given for caesareans:

Bigger babies. "True, we are growing bigger babies. But the fact is, we have bigger mothers too. The growth charts have not altered in as long as I can remember. There is a saying in midwifery - mothers grow babies to fit their bodies. I have seen a lot of caesareans for a suspected big baby, and they turn out to be normal-sized.

Failure to progress. "Or, as we say, failure to be patient. If mum and bub are fine, why the rush to hurry the labour? Some are slow achievers, and some are speedy. It doesn't matter how fast labour progress, so long as mother and baby are well. It is more likely the hospital staff getting nervous and wanting the baby out, so their shift can finish.

• Increased surveillance. "There is a trend to monitor the mother and baby more closely with heartbeat and contraction monitors. And while this is necessary in many cases, such as induction of labour, or high-risk pregnancies, it often prevents a mother from being able to move freely and birth as she feels comfortable. The other issue is, any deviation from normal in the baby's heartbeat is pounced on. When often we don't understand that babies go through sleepy and active phases, they also go through some pressure when coming through the birth canal and it is normal at this time for the baby to momentarily drop its heart rate. But these deviations from 'normal' are not tolerated for long before further intervention is often suggested," said Ms Wakefield.

What Midwives can do

There are many strategies that Australian midwives can implement to help women avoid unnecessary caesarean sections, said Ms Wakefield, including: 

Education on a healthy diet, exercise and lifestyle factors for woman and their partners who are planning on conceiving.
Normalise birth. Ask the woman to talk about her thoughts, feelings and expectations around birth. Help to de-bunk myths she has come to believe through stories and media exposure.
Birth education. Encourage women to attend quality independent birth education, that is relevant to where they are birthing, such as Hypnobirthing Australia™, SheBirths, Calm Birth.
Teach women "optimal maternal positioning" techniques, to help them understand where their baby is positioned and how to help move the baby into a position more conducive to fitting out.
• Have a known midwife. Continuity of care should be available for all women. When a woman knows her midwife, it helps her to feel safe and supported.
Teach coping strategies in the early stages of labour at home. If a woman comes in too early, she is more likely to have more intervention, and the more intervention, the more likely the chance of a caesarean.
Teach how to remove fear and how to tap into endorphins and oxytocin.
The birth room. Keep the room quiet and dark to enhance oxytocin. Minimise unnecessary people coming into the room. The birthing space should be as sacred as the conception space. Honouring that for a woman will help her feel safe.
Gain rapport early, so that if and when intervention is necessary, the trust has been established.

"Always remember this birth is this woman's birth. It is a day she will remember forever. Every word will be etched in her psyche for the rest of her life.

"It is a privileged position to be a midwife. So, as a midwife, make sure the woman feels special," said Ms Wakefield.

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Haley Williams

Haley Williams has a Bachelor of Communication in Journalism and over a decade of experience in the media, marketing and communications industries.

She is a widely published journalist with a particular interest in writing magazine features on parenting, health, fitness, nutrition and education.

Before becoming a freelance journalist, Haley worked as a writer for NeoLife (a worldwide nutrition company), News Limited and APN News & Media.

Haley also has extensive experience as an SEO Content Writer and Digital Marketing Strategist.