If you follow any pregnancy or birth accounts on social media, it’s likely that over the past couple of weeks you have heard that medical interventions in labour and birth are rising in Australia, and that despite skyrocketing interventions, our maternity system is failing to save more babies.
Last week the Australian Institute of Health and Welfare released their annual report into Mothers and Babies. To no-one’s surprise, it confirms what every doctor, midwife or doula working in pregnancy care, and in fact any person who has birthed in Australia in the last few years already knows. Interventions are on the rise.
Over the last decades, our public and private hospitals around Australia have seen a steady increase in the number of women who birth their babies with the assistance of a doctor, using either the vacuum cup, the obstetric forceps, or via caesarean section. There has been an overall increase in the number of women whose labour has been induced (medically started) and a corresponding decrease in the number of women whose labour starts naturally.
Perhaps, you may wonder, this rise in intervention could be justified if it could be shown to reduce the number of babies dying. According to the headlines that have dominated social media circles and in conversations throughout hospital maternity units this week, that is not the case. As a result, the take home message for thousands of pregnant people this week has been that despite our increased meddling in the natural birth process, the overall safety and the chance of your baby dying remains the same.
The only problem with this analysis? It’s not true.
Like all statistics around a process as complex as the human body and birth, it is possible for statistics to be extremely misleading when used in the wrong context. In this case, a nuanced look at the statistics shows the opposite to be true.
The common statistic that has been picked out this week and held up as proof of a failing system relates to the total number of babies dying after 20 weeks of pregnancy. Sadly, it is absolutely correct that overall a similar number of babies are dying beyond 20 weeks of pregnancy now that were dying two decades ago. In Australia, this is known as the Perinatal Mortality Rate, and it has remained stubbornly steady over many years.
However the overall Perinatal Mortality Rate (PMR) is not relevant to discussions regarding interventions in birth. Why? The overwhelming majority of deaths that now make up the PMR are for babies born under 28 weeks gestation, in particular babies born between 20 and 22 weeks of pregnancy. In fact, in 2019 there were more stillborn babies born in just the two weeks between 20 and 21 weeks of pregnancy, than the total number of stillborn babies born at any point after 32 weeks of pregnancy.
These very early deaths are due to spontaneous preterm birth, before a baby can survive outside the womb, as well as an increasing number of terminations of pregnancy that are being performed for families who choose not to continue with a pregnancy affected by a congenital or genetic abnormality. Over the years, the proportion of the PMR that is made up of these extremely preterm babies has risen significantly.
However the wonderful news for birthing families is that over this same timeframe, the rate of babies dying after they have reached the third trimester of pregnancy has dropped significantly. In the year 2000 the number of babies that were stillborn after reaching 28 weeks of pregnancy was 3.8 for every 1000 births. Fast forward nearly two decades to 2019, and this rate has dropped to 2.6 babies stillborn for every 1000 births. Similarly, the number of babies that die shortly after birth, after reaching the last trimester of pregnancy was lower in 2019 when compared to two decades earlier.
I should pause at this point to be very clear that the loss of a baby at any point during a pregnancy is a tragedy. For a baby to die at 21 weeks of pregnancy, regardless of the reason, must in no way be considered less of a loss than when a baby dies at 40 weeks of pregnancy. The trauma that comes with the loss of a child is not related to something as trivial as a number of weeks written on a hospital form. For families, the grief of losing a baby at any stage of a pregnancy is life-long and profound.
However, when discussing the impact that rising rates of intervention in labour and birth has had on safety for babies, it is extremely important to make this distinction. The rate of babies dying before 28 weeks is incredibly important, but it is not relevant to discussions around the safety of caesarean birth, induction of labour, or instrumental birth at term.
To claim that babies are dying at the same rate despite increasing birth interventions is extremely misleading. In fact there has been a clear reduction.
It is also important to note that this improvement in outcomes has occurred despite the steady rise in pregnancies with a higher risk of late stillbirth. Increasing maternal age, increasing rates of maternal obesity, increasing IVF pregnancies, and an increasing number of people going into pregnancy with high risk medical conditions such as Type 2 Diabetes means that, all else being equal, we should have expected to see an increase in late stillbirth and neonatal death. The fact that we have seen a reduction in late stillbirths and neonatal deaths, despite the rapid rise in higher risk pregnancies and births, is a fantastic outcome.
Therefore, an accurate reading of the statistics establishes that in the last two decades in Australia birth interventions are increasing, whilst rates of late stillbirth and neonatal death are decreasing, despite overall higher risk pregnancies. This is reassuring. However it can not, and should not, be the end of the story.
We can acknowledge that timely interventions in modern obstetrics can and do save lives, whilst still scrutinising our rising rates of intervention and interrogating how we may be able to do better for individual families. For example, current technology that is used to monitor mothers and babies is far from perfect. Tests that determine how a placenta is functioning, how a baby is growing, and the oxygen levels for babies during birth are not perfect. Midwives and Obstetricians around Australia are making the best recommendations they can based on our current knowledge and technology. Sometimes we err too far on the side of caution. Sometimes we get it wrong.
Fortunately, there has been a significant worldwide focus around reducing the tragedy of stillbirth, with increasing research dedicated to understanding what leads to some babies to die in utero or suffer a brain injury due to lack of oxygen during birth, as well as improving our tests that will allow us to detect more accurately who is at risk. This will allow us to target interventions to those who stand to benefit the most. The overall focus for many is to minimise interventions wherever they are not wanted or needed, without unnecessarily risking lives. There is much work to do.
In order to achieve this, we must also recognise that for some birthing people, intervention is not inherently a bad thing. The rate of caesarean on maternal request, for example, is steadily rising, as is the number of women requesting a planned epidural in labour or an induction of labour at term without an underlying ‘medical indication’. For these birthing people, intervention is their preference, not their problem.
On the other hand, and just as valid, are the many birthing people with a deeply held belief system around honouring and trusting the natural processes of birth and avoiding any medical intervention unless absolutely necessary and only if all other options have been explored. Many people research their options and fall somewhere in between these two approaches.
Alongside this understanding, there is an increasing recognition that birth can not simply be reduced to a table of statistics such as the perinatal mortality rate in a government report. For many, birth represents a magical, transforming, and singular life experience. In a society that is increasingly medicalised, sterilised and bureaucratically organised, birth can represent a link to our past, a connection to our innate animal instincts, and a rite of passage.
Our understanding of what birth represents to birthing people, and what a safe and good birth looks like, is knowledge that has been suppressed by decades of institutionalised birthing. When birthing moved out of the home and into hospitals early last century, the predominantly patriarchal medical system placed obstetricians at the centre of decisions, and safety of the baby at the forefront of care. In this medical model, the women’s preferences, physical healing and emotional recovery after birth have historically been an afterthought, at best.
It is in the shadows of this recent history; of routine enemas, pubic hair shaving and a compulsory sterile field for birth; that the current era of modern obstetrics emerges. We must acknowledge that whilst birth has never been safer in Australia, rates of women reporting birth trauma are shockingly high. Some of this trauma following birth relates to the inherent risks and genuine life or death emergencies that may occur without warning during birth for mum or baby.
Some birth trauma relates to our failure to educate birthing people about how we may better prepare for birth and the reality of what to expect during labour. Some birth trauma relates to women being disbelieved, disrespected, and being denied access to interventions when they are requested or needed, such as timely caesarean birth or epidural pain relief. And some of this trauma, undoubtedly, relates to the experience of birthing people who have interventions thrust upon them that they neither consent to, need, or want.
I work with incredible midwives every day who lament the loss of the spontaneous, unhurried and natural birthing experience that many women wish for, but for many different reasons, are not able to experience. Modern obstetrics has become incredibly good at keeping mothers and babies alive. For many people, this is all that matters. But for some, there is so much more to birth.
This is the point where we must acknowledge that when it comes to something as important as childbirth, there is rarely a clear right or wrong approach. This is because different people place different values on various aspects of their birth experience. In addition, risk is a subjective, confusing and slippery concept.
Many birthing people preference safety above all else. A risk that is tiny in absolute terms, such as the difference between 1 in a thousand babies dying, compared to 2 in a thousand babies dying, is a risk that many women are simply not prepared to take. A birthing person may request an intervention, such as induction of labour or elective caesarean section, to prevent what may be an incredibly rare outcome. This is neither right nor wrong. It is simply what is right for them, and should be respected and supported.
Given the same set of statistics, another birthing person may place higher value on the natural process of birth, and may decline the same intervention. This is neither right nor wrong. It is simply what is right for them, and should be supported and respected
There is no correct way to give birth. All births are equally valid and beautiful. What is important is that women know about their birthing and support options. What is important is that they are informed about any risks that may be relevant to their specific circumstances in a clear, unbiased, and respectful way.
What is important is that they are also told about the risks of accepting interventions, as well as being informed of other options and what that may involve. What is important is that birthing people are given time to consider their preferences. What is important is that those preferences are respected. Most importantly, what is important is that women feel supported and safe when giving birth, whatever that birth may look like.
Australia is one of the safest places in the world to birth a baby. This does not make our system perfect. Far from it. We have a long way to go if we wish to achieve the goal of establishing true collaborative care between midwives and doctors, and for every woman to emerge from birth feeling heard and respected, knowing that the importance of their birth experience has been recognised, no matter how their baby comes into the world.
In order to achieve this goal, we need to have an honest discussion around birth choices and interventions. This is an incredibly important discussion that everyone working and interacting in the birth space must be a part of. It is a topic that is too important to be clouded by misinformation.
We must acknowledge the rising rates of intervention that are undoubtedly occuring in birthing units all around the country. We must understand and respect the different values and preferences that each birthing person brings to their experience. We must acknowledge the incredibly low overall rates of fetal and neonatal death in this country, as well as the improvement that we have seen in the rates of late stillbirth and neonatal death over the last two decades. We must do all this whilst all asking ourselves; How can we do better?