Hey there! If you are just joining us, this is the second part in a 3-part series of How to Choose your Maternity Care Provider. If you missed part 1, go back to the last blog post and review the questions to ask yourself when visualising your birth, before actually choosing who will provide your pregnancy care and attend your birth.
Next Step: Decide WHERE would you like to birth and with WHAT model of care.
Now that you have clarified your birth vision and obtained a referral from your GP, it's now time to decide your birth place and model of maternity care. These decisions are made simultaneously (for the most part), but they are not completely the same. It depends on what is important to you: if the location of your birth is most important, that will narrow down the providers that can attend your birth. But if the type of care provider you want or need is most important to you, then this narrows down your birth place options.
Let's first look at WHERE you would like to have your baby:
Public Hospital Birth and/or Birth Centre
The majority of women in Australia birth in a public hospital (75%). If you have a Medicare card (i.e. you are an Australian/New Zealand citizen or permanent resident), then your care will be either completely free or at minimal cost. If you are low-risk, you’ll be cared for by midwives in your particular model of care (see more on that below!). If you have risk factors or pregnancy complications that make you "high-risk", you’ll also interact with obstetricians. During your labour, if you desire medical pain relief including getting an epidural, you will have access to an anaesthesiologist in the hospital labour and birthing suite. Many public hospital birthing suites are equipped with birthing pools, and provide the opportunity for you to have a water birth if you so choose. Call your nearest public hospital and ask them what is available.
You may also have the option to have your baby in a birth centre attached to a public hospital. Click here for a list of birth centres by state. If you have an uncomplicated pregnancy and desire a low-intervention birth, a birth centre may be just the place for you! Birth centres are made to feel more like a home-away-from-home and often have a double bed, a sofa, an ensuite bathroom with birthing tub. These birth centres are most often available for women who are under the care of a public Midwife Group Practice (MGP) (more on that below). One great advantage to a birth centre is that it is attached to the public hospital. If a situation develops in your labour that requires a higher level of medical care (i.e. an obstetrician, anesthesiologist or other specialist), you are literally right down the hall, and could be transferred to the main birthing suite if necessary.
Private Hospital
One of the main reasons women choose to birth in a private hospital is that they are free to choose their private obstetrician (more on this in Part 3 of this series). Other private hospital perks include having a guaranteed private room which your partner can stay overnight with you, and you can stay longer in the hospital if you desire to. If you have private health insurance, you can expect to pay $3,500 - $5,500 (on top of your insurance premium) for the hospital fees. You’ll also have to pay your private obstetrician a pregnancy management fee, which can be anywhere from $2,500 - $3,400 (and is usually required to be paid prior to the birth). You can be reimbursed a portion of these fees by applying for Medicare rebates. Your private options also depend on what kind of private health insurance you have, so check your policy. Here's a good link for when you're thinking about private insurance maternity cover. If you did not have private health insurance and wanted to pay out of pocket, you can expect to pay upwards of $20,000 for your pregnancy care and birth[1].
Home Birth
If you desire minimal intervention in your birth, and would prefer to be in your familiar environment, you might be interested in having a home birth. There are numerous studies that report that home birth is just as safe as birthing in the hospital. A meta-analysis of 14 studies published in 2019 in The Lancet, a prominent peer-reviewed medical journal, examined data from over 500,000 intended home births and found that “the risk of perinatal or neonatal mortality was not different when birth was intended at home or in hospital.” (Hutton et al 2019)[2]. In 2021, over 1,500 home births (about 0.5% of all Australian births) occurred at home[3].
To access the opportunity of home birth through the public system, you would need to apply to be in an Midwifery Group Practice (MGP) which offers a home birth program. Alternatively, you could hire a Private Practicing Midwife (PPM) to attend your birth at home. Either way, you will be attended by two registered midwives, who bring standard emergency supplies and are endorsed to administer IV/IM medication including Syntocinon, Ergot (methergine), and IV fluid, in the case of a haemorrhage. The midwives are also trained to manage intrapartum emergencies and to know when to consult with obstetricians and transfer to the nearest public hospital if needed.
A word on deciding which birthing location is for you: Get informed!
If you are hoping to avoid an unnecessary caesarean, “The biggest risk factor for the most common surgery performed on humans is not a woman’s personal preferences or even her medical risk, but which facility she goes to, which door she walks through,” says Dr. Neel Shah, MD, MPP, is an Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School.[4]
Furthermore, if you are thinking about birthing in a private hospital, consider this: “Women in Australia are more likely to have an unplanned caesarean birth if they give birth in a private hospital rather than a public hospital – independent of their health status during pregnancy or their birth plans.” – says an article in The Conversation[5]. A research study published in 2022 by the University of Technology, Sydney (UTS), the University of New South Wales (UNSW), and the Burnett Institute in Melbourne, in a review of over 289,000 births, found that having an unplanned caesarean birth was 4.2% more likely in a private hospital than a public one[6]. The percentage was even higher for first time mums. You can read the actual research article here.
If you live in New South Wales (NSW) or Victoria, it’s easy to find information on any hospital facility! You can find the birth statistics (vaginal, caesarean, and instrumental birth rates) of any particular hospital (public and private) by downloading your state's latest report. For NSW, click this link for the NSW Mothers and Babies Report. If in Victoria, check out the Victorian Perinatal Services Performance Indicators. Just search the pdf document for the name of your hospital in the “find” function. For an even easier way, check out @birthstats_nsw or @babybirthstatsvic on Instagram. Both of these IG handles do a great job synthesizing the information provided in their respective state reports and give the break down of the numbers on every hospital in NSW and Victoria in an easy to read format.
Next Step: Choose WHAT model of care is best for you: Public vs Private
In Australia, there are at least 11 models of maternity care in the health care system. It can be confusing, even overwhelming. Here’s a diagram to help make sense of it. Just follow the coloured lines from your ideal birth place to their respective model of care. Easy, right? (I'm being facetious, here).
Again, the number of care model options you have depends on whether you have Medicare and/or additional private hospital insurance. The care you receive would be most ideal if there is continuity with one provider, someone who knows you, knows your history, and can follow you through your pregnancy, birth, and postnatal period. You can find public midwifery continuity-of-care options of either Midwifery Group Practice (MGP) and Team Midwifery Care. Private continuity-of-care options are either a Private Practicing Midwife (PPM) or Private Obstetrician (see Part 3 for a full description). Your continuity-of-care provider would collaborate with the high-risk specialist clinic if your pregnancy required their consult. Care models that are not considered to provide continuity are the public hospital antenatal outpatient clinic, GP-Shared Care, Maternity Antenatal Postnatal Service (MAPS), and "Combined Care".
The remainder of this post will discuss the public care model options. For more information on private care options, be sure to check out Part 3 (the final post) of this series.
Public Options
Continuity of Care: Midwifery Group Practice (MGP) and Team Midwifery Care
Midwife‐led continuity models of care are considered the “gold standard” of maternity care. A Cochrane Database of Systematic Reviews in 2016 found that women who had “Midwife-led continuity of care models were less likely to experience intervention and more likely to be satisfied with their care [7].
To receive care from the same midwife throughout your pregnancy, birth and postpartum, your best public care model is a Midwifery Group Practice (MGP). You will be assigned a primary midwife, but will also meet a team of about 3-5 midwives, who may look after you antenatally as well, and attend your birth in the public hospital, a hospital birth centre, or at home (if your local health district has an approved home birth program). Your MGP midwives would visit you postnatally in your own home to assess your recovery, provide a well-baby check and provide breastfeeding support. Yet, it can be very difficult to secure an MGP placement, as you must call your hospital antenatal outpatient department as soon as you know your pregnant to secure a spot. Most MGP programs will require your referral letter from your GP. Each MGP takes a very small amount of expecting mums each month (approximately 4-6 women per month depending on the size of their team), as they must balance a rolling caseload of all other women who are due in the successive months before you.
Another alternative to MGP is Team Midwifery Care. This is a team of midwives (usually 5-8) that are rostered on at the hospital in shifts for antenatal, intrapartum labour and birth, and postnatal visits. The woman is not assigned a primary midwife, but is looked after by whomever is scheduled that day/time of service. So over the course of your visits, you would get to know the entire team of midwives. This midwifery team works together with each other and in collaboration with other doctors at the public hospital and birth centre.
MAPS, GP-Shared Care, Hospital Antenatal Clinics and High-Risk Specialty Clinics
An alternative to MGP, that is almost continuity-of-care (but not quite) is the Maternal Antenatal Postnatal Service (MAPS) which is available at some local health district/public hospitals. This option offers continuity-of-care with the same primary midwife and team of midwives in both the antenatal and postnatal periods, but while you are in labour in the public hospital, staff-midwives (whom you haven't met) would care for you and attend your birth.
When you have GP-Shared Care, you are looked after by your primary GP and by antenatal clinic midwives and obstetricians through a schedule of rotating office visits. Shared-Care GPs are primary doctors with additional training in women’s health and pregnancy and are affiliated with your local public hospital. When you report to the hospital antenatal clinic, you may not see the same midwife every time, and may end up repeating your information multiple times as you interact with various clinic providers. Should you have risk factors or complications develop in your pregnancy, you would be referred to a high-risk clinic at the hospital (Diabetes Clinic, Medical Disorders in Pregnancy, Maternal Fetal Medicine, Twins, Breech Presentation, Preterm Birth) to access, more medical, specialised care.
Why go public?
The biggest benefit to choosing a public option model of care is that it is mostly free health care (covered by Medicare), and would result in minimal costs to you. If you can secure a midwifery continuity-of-care, you would know your care team throughout your pregnancy, birth and postpartum journey, and more importantly, they would know you - your wants, needs, and other considerations. Birthing at a public hospital, you would also have access to other medical specialists, physio providers and lactation consultants if you required their consult.
However, one thing to keep in mind is that choosing a public model will require your provider to abide by specific set of public hospital policies and procedures. For example, you may want to have a Vaginal Birth after Caesarean at home, but you would not meet approved criteria under the public Local Area Health District policy. You may have more options available to you to birth at home, if you hire a Private Practicing Midwife (see Part 3).
Phew! That was a lot. Thanks for reading thus far. Hopefully, I've helped you understand more about your birth place options and about public models of maternity care. To learn more about hiring a private maternity care provider, whether that be a Private Midwife or Private Obstetrician, make sure you click on the final part of this 3-part series!
References:
[1] https://kinfertility.com.au/blog/how-much-does-it-cost-to-give-birth-in-australia#:~:text=Cost%20of%20going%20private%20(with%20health%20insurance)%3A%20%243000%2D%245000&text=Obstetrician%20fee%20(sometimes%20dubbed%20a,%242%2C500%2D3%2C400%20%5B4%5D.
[3] https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/contents/labour-and-birth/place-of-birth
[5] https://theconversation.com/private-obstetric-care-increases-the-chance-of-caesarean-birth-regardless-of-health-needs-and-wishes-178032
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