A few weeks ago, the Australian Institute of Health and Welfare (AIHW) published their annual Australia’s Mothers and Baby Report. The report is a collection of national perinatal data from the previous two years, which in effect means that the 2021 report contains 2019 data, and therefore we are yet to see the full impact of COVID-19 on birth outcomes. 

Anecdotally, many birth professionals (midwives, doulas, and childbirth educators in particular) have noted with concern a significant increase in birth interventions - particularly induction of labour, episiotomy, instrumental birth (vacuum and forceps delivery) and cesarean section -  with little to no improvement in birth outcomes. The data now backs up what we all suspected was happening and this is not good news for birthing people in Australia. 

Here’s a snapshot of some of the high-level findings of the report:

In 2019, there were 303,054 babies born to 298,567 parents in Australia. The majority of births (97%) in Australia occur in hospitals, 1.8% of people give birth in birth centers and 0.3% at home (Dahlen et al, 2020). The average age of people giving birth has been rising over time, for both first-time parents (from 27.9 years in 2009 to 29.4 in 2019) and those who have given birth previously (from 31.0 years in 2009 to 31.9 in 2019). The highest proportion of birthing people were aged between 30 and 34  (more than one-third (36%) of all who gave birth).

Induction of Labor 

Almost 1 in 2 (46.8%) primiparas (a person giving birth for the first time) had an induction of labor. In my state of Victoria, the induction rate was even higher at 51.5%, which represents a 20% increase in less than 10 years! Personally, I have heard many stories of people having their “just in case induction” date booked in at their very first antenatal appointment, sometimes as early as 12 weeks of pregnancy. What has also slowly crept in as routine care are membrane sweeps (also known as a “stretch and sweep”), commonly performed at an antenatal appointment between 37-39 weeks of pregnancy, despite a lack of evidence to support their efficacy in starting labour. People are often not even told that this is what is being done to them, which is a clear violation of their bodily autonomy and basic human right to consent or decline to any treatment or intervention. Pregnant people are being encouraged to have a stretch and sweep as a means of avoiding an induction, However, a stretch and sweep is, in fact, a form of induction. It is an intervention and people need to be informed as such. 

Cesarean Section

The World Health Organization (WHO) states that, at the population-level cesarean section rates higher than 10-15% are not associated with reductions in maternal and newborn mortality rates (WHO 2015). The WHO also states that cesarean sections are effective at saving lives when required for medically indicated reasons, and every effort should be made to provide cesarean sections to people in need, rather than striving for a specific rate (WHO 2015). The Organisation for Economic Co-operation and Development (OECD) also tracks cesarean data as well. The cesarean section rate has increased internationally between 2000 and 2019 (OECD 2021). 

Australia’s cesarean section rate was higher than the OECD average over this time and ranked 27th out of 34 OECD countries in 2017, with a rate of 33.7 per 100 live births (ranked from lowest to highest) (OECD 2019). In 2019, 36.0% of all people giving birth in Australia had a cesarean section (AIHW 2021). This figure combines both public and private hospitals. In Australia, approximately 70% of people birth in the public system (primarily midwife-led), with the remaining 30% birthing in the private system (obstetric-led). Cesarean rates in private hospitals are difficult to calculate given they vary from obstetrician to obstetrician. Private hospitals are most definitely not subjected to the same level of scrutiny and transparency that our public healthcare system is. 

Vaginal Birth after Cesarean (VBAC)

Contributing to the high cesarean section rates are the low numbers of people having a vaginal birth after cesarean section (VBAC). The VBAC rate is 15.3 percent for people who give birth in public hospitals and only 5.8 per cent in private hospitals. For people seeking a VBAC following two prior cesareans, it is almost impossible to find a healthcare provider who will support that, even though current evidence states that a TOLAC after two prior cesareans should be considered. (ACOG, 2017)  Not having this option forces people to opt for birthing choices outside the system, such as freebirthing if they want to birth vaginally. 

In 2020, Professor Hannah Dahlen, together with Bashi Kumar-Hazard and Virginia Schmied co-edited Birthing Outside the System: The Canary in the Coalmine. This fascinating book investigates why people choose ‘birth outside the system’ and makes connections between women’s right to choose where they birth and violations of human rights within maternity care systems.

Instrumental Birth

The rates of instrumental birth are also on the rise, with my state of Victoria coming in with the highest rate in Australia (31.4%, compared with a national average of 26.2%). Not surprisingly, an increase in instrumental births also leads to an increase in episiotomies. 79.6% of people who had an instrumental birth also had an episiotomy. Almost 1 in 4 people (23.2%) had an episiotomy following a vaginal / non-instrumental birth.

Perineal Tearing 

The controversial Perineal bundle was introduced in Australia in 2018 with the aim to significantly reduce the rate of severe 3rd & 4th degree tears.

Despite the widespread introduction of these supposed preventative measures, the AIWH report showed that there has been no change in the rate of severe 3rd and 4th degree perineal tears (2018 = 2.9% and 2019 = 2.9%). Even going back to 2013, the national rate was 3.0% so hardly a significant improvement and this is reflected in individual states and territories as well.

Conclusion

What does all this mean for the state of birth in Australia?

Professor Hannah Dahlen couldn’t have said it better in her recent op-ed; 

“If maternity care had shareholders, the whole board would be sacked. Where is the accountability to the taxpayer who funds this highly costly care, and most importantly, where is the accountability to women and babies?”

Unlike the United States, Australia provides all permanent residents and citizens with free healthcare, under the Medicare scheme. This includes maternity care, which around 70% of people utilise by birthing in public hospitals. The remaining 30% opt for private obstetric care, which is paid for with private health insurance. 

As childbirth educators, we play a critical role in informing and educating families about the maternity care system. While it’s all well and good to practice comfort measures and active labour positions in class, without the knowledge and understanding of the system in which they are having their baby, they are highly likely to find themselves hurtling along the conveyor belt of birth. When the system itself undermines (if not outright sabotages) normal, physiological birth, birthing people and their partners need access to evidence-based information and the tools to be able to make confident, informed decisions about their care. 

Unfortunately, by the time most people find themselves in a birth class, (if they do one at all), they are usually in the final trimester of pregnancy, making it more or less impossible for them to change their care provider or model of care. Less than 10 percent of Australian pregnant people access one-to-one midwifery-led care. While most people will still be cared for primarily by midwives, they will receive “stranger” care, with no continuity of provider throughout their pregnancy or during their labor and birth. One thing we can all proactively do as educators is to use our various platforms (social media, blogs, podcasts etc) to inform and educate families early in their pregnancy about the other birth options that are available. We know from research that the model of care a person chooses can significantly impact the birth interventions they end up with.  (Sandall, J., et al, 2016) 

I do believe that we can turn the tide on this “intervention epidemic” but ultimately the only people who can demand change are birthing people. It’s time for us all to say, “enough.”

References

American College of Obstetricians and Gynecologists. (2017). Vaginal birth after cesarean delivery. ACOG Practice Bulletin No. 184. Obstetrics and Gynecology, 130(5), e217-e233.

Australian Institute of Health and Welfare. (2021). Australia's mothers and babies. Retrieved from https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies

Betran, A. P., Torloni, M. R., Zhang, J. J., Gülmezoglu, A. M., WHO Working Group on Caesarean Section, Aleem, H. A., ... & Zongo, A. (2016). WHO statement on caesarean section rates. BJOG: An International Journal of Obstetrics & Gynaecology, 123(5), 667-670.

OECD (2021), Caesarean sections (indicator). doi: 10.1787/adc3c39f-en (Accessed on 09 December 2021)

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models of care compared with other models of care for women during pregnancy, birth and early parenting. Cochrane Database Syst Rev, 4, CD004667.

About Tanya Cawthorne

Tanya Cawthorne is a Lamaze Certified Childbirth Educator, Doula and Lamaze Program Director based in Melbourne, Australia. In 2018, she co-founded Lamaze Australia, the first international affiliate of Lamaze International.  Tanya is also currently serving as the President of Lamaze International.

Tanya is a passionate advocate for evidence-based, woman-centred maternity care and is a prolific writer on all things related to birth and early parenting. Her articles have appeared in The Journal of Perinatal Education, Australian Midwifery News, Connecting the Dots, Interaction – the journal of the Childbirth and Parenting Educators Association of Australia (CAPEA), International Doula, Empowering Birth Magazine and Rockstar Birth Magazine.

Last, but definitely not least, Tanya is also a proud single mum of two beautiful children; her son Liev and daughter Amalia.

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