Australia’s maternity system, led by midwives, faces a birth trauma crisis

26551346 - ptsd signs

I wrote only two weeks ago about the abuse of obstetric patients in the midwife led systems of four countries, Ghana, Guinea, Myanmar, and Nigeria. A study in The Lancet raised the alarm.

The abuse was tied to patient age and social standing suggesting that it was a reflection of power relationships. These are all midwife led systems with very few doctors. The authors postulate that gender discrimination within these countries means that women who finally have some power over others may take advantage of that power.

Why do midwives cause so much birth trauma and what are they going to do about it?

Now comes word that women in Australia, another country with midwife led maternity care is facing a birth trauma crisis.

According to Australia’s maternity care at ‘crisis point’ with birth trauma rates increasing in today’s news.

Up to one in three Australian women have experienced birth trauma and one in 10 women emerge from childbirth with post-traumatic stress disorder (PTSD) and according to researchers, the problem is getting worse.

Toowoomba mother Jessica Linwood clutched her husband Daniel’s hand as she described the birth of their first child — when she experienced a postpartum haemorrhage — as “terrifying”…

“[A] midwife was pushing on my stomach to contract my uterus back down.

“I had said it hurt and [that] she was hurting me and she told me that I [would] die if she didn’t do it.

The midwives and doulas of Australia, though their lobbying group, blame the problem on medicalization.

The Maternity Consumer Network (MCN) has blamed the problem on overmedicalisation during childbirth, and said the national caesarean rate of 34 per cent was three times the rate recommended by the World Health Organisation.

But C-section rates have been rising for at least two generations and have held steady for the past decade; birth trauma, in contrast, has only become a problem relatively recently, as midwives have gained more power within maternity systems. The dirty secret about birth trauma is that midwives are responsible for a lot of it.

Why? Because they promote their OWN interests over the interests and needs of patients. Indeed, the Australian midwifery group behind the MCN has as its motto: “Midwifery Continuity of Care for Every Woman.”

Not, ‘Safe Care,” not ‘Respectful Care,” but ‘Midwifery Care.’

At the heart of midwifery abuse of patients is the fact that midwives, while claiming to be with women, promote “normal birth,” a midwife-centered, one size fits all model of care. It’s hard to imagine anything more disrespectful  and traumatizing than telling women how they ought to give birth and ignoring what they might want (pain relief, interventions, maternal request C-section), yet this is precisely what campaigns for normal birth do.

The article itself is a form of astroturfing.

According to Merriam Webster, astro-turfing is:

organized activity that is intended to create a false impression of a widespread, spontaneously arising, grassroots movement in support of or in opposition to something (such as a political policy) but that is in reality initiated and controlled by a concealed group or organization (such as a corporation).

This article and others like it are intended to hijack the serious problem of birth trauma for the benefit of midwives, the very people causing the problem.

Don’t believe me? Look who is quoted in the article, a midwifery leader, an executive at a midwifery group, a pro-midwifery lawyer.

The Australian midwifery leader Hannah Dahlen wants more midwives:

Professor Dahlen said women who had continuity of midwifery care — the same midwife through pregnancy, labour, birth and six weeks post-partum — had less medical interventions and were more satisfied with their births.

The midwifery executive wants more money:

“If we actually started to move some money into that bucket we would see benefits in spades.”

And the pro-midwifery lawyer, Bashi Hazard, refuses to acknowledge that midwives are responsible for a great deal of birth trauma. Several weeks ago I asked her publicly on Twitter to explain the difference between a doctor who performs a painful exam over a woman’s protests and a midwife who denies an epidural over a woman’s protests. She mounted an extended tantrum in an effort to deflect attention from the fact that she couldn’t supply an answer.

What would it look like if midwives actually cared about birth trauma instead of merely weaponizing it to increase midwifery funding and employment?

The first thing they would do is admit their own complicity and set up training programs FOR MIDWIVES to address THEIR ROLE in causing birth trauma. They would stop promoting normal birth, which reflects THEIR preferences and start respecting patient preferences.

But that’s not going to happen since this isn’t about preventing birth trauma; it’s about promoting midwives.

  • Anj Fabian

    The article referenced vaginal birth and yet Dahlen was pounding the c-sections are the devil drum.

  • AnnaPDE

    Oooh, and now this one:
    https://www.theguardian.com/australia-news/2019/nov/01/out-of-pocket-costs-for-birth-in-private-system-shocking-midwifery-expert-says
    “Exclusive: study shows women with private cover pay considerably more than those who go to public hospital”
    with the money quote at the end by Hannah Dahlen:

    “It’s quite shocking, and I didn’t realise the out-of-pocket costs were as bad as this study points out. Especially the cost of a caesarean in the private sector. I think a lot of women were led to believe that private health will cover everything.”

    But she said people were increasingly dropping out of private health cover or never taking it up in the first place, particularly young women.

    “A lot of women who give birth in the public system can’t believe the continuity of midwifery care they get. They get this amazing gold standard of care they don’t have to pay as much for as they would privately,” Dahlen said.

    What she doesn’t realise is that while people increasingly don’t take up private health cover plans, they still go for the private obstetric care and just pay 100% out of pocket. I for one did exactly that.

    Because women aren’t stupid, and they want to be sure to get proper, qualified, Obstetrician-led pregnancy care with close state-of-the art monitoring, and access to elective or at least timely C-sections. Both of which are very hard to get in the public system that is focusing on “continuity of midwifery care” and ignoring what women are actually asking for.

    • mabelcruet

      I can see the way her mind is going “Women are willing to pay that much for care? And its all going to doctors, and none to me? Well, how can I get a cut of it?”

      It’s very obvious from the way she’s desperately promoting midwifery led care and fluffing up the ‘gold standard’ care the midwives can provide. Her only concern is her pocket-follow the money. It’s nothing at all to do with who provides the safest care, its to do with who gets the money.

    • Ozlsn

      The main reason women shifted back to the public system was the government rebate for private obstetric care reimbursement dropped to the point it was unaffordable for a lot of women. Private health insurance covers the hospital costs – not the obstetrican appointments beforehand. I was hospitalised early enough that most of my costs were covered. I do think the team model can work – it is better having continuity of care rather than seeing a different person every appointment – but I also strongly believe that obstetricans need to be an integral part of that team, even if they don’t see the woman at every appointment. And if something is out of the ordinary (e.g. from last year a woman presents with normal BP, but odema, proteinuria, headache and visual disturbance) they need to be called in to review ASAP.

      • AnnaPDE

        Yes, continuity of at least the care team would be very desirable. I just don’t get why this kind of care is only available privately. In my simplistic European view I’d always thought that this is the standard way of doing it.

  • Glia

    Professor Dahlen said women who had continuity of midwifery care — the same midwife through pregnancy, labour, birth and six weeks post-partum — had less medical interventions and were more satisfied with their births.

    Oh, people who don’t have things go wrong enough to need to be transferred to higher level care have better experiences on average than people who do have things go wrong? Needing more medical interventions results in more medical interventions? What stunning revelations.

    • ozlsn

      Also seriously some of the quotes and analogies in that article made me really angry. Women are not being “sent out on the battlefield” for crying out loud. The whole first story basically is saying that both the woman and her partner would have appreciated more support, both after her first delivery and during her second pregnancy. More clinics where women and partners could discuss what happened and why with providers would be useful. Midwifery led care in the next pregnancy – not so much unless they are including counselling services in that care (and the midwives doing that have appropriate qualification to do that). Especially if the woman is now considered high risk and needs to be being followed up in the high risk group which should be being led by an obstetrician with a midwifery team.

      I notice that the first woman quoted in the article doesn’t actually mention who the care for her second pregnancy was through – but if her PPH was severe enough that she was very traumatised then I suspect she wasn’t through midwifery-led care.

      • ozlsn

        And also (replying to myself because I am apparently still angry, even after deleting all the swear words from my first post) – how would midwifery-led care have prevented the first woman’s PPH in any way, shape or form here? I also notice that they didn’t ask her if she had a serious PPH during the birth of her second child, and if being prepared for the likelihood and management of it was part of the reason it was less stressful?

        This is the kind of bullshit that leads women like Caroline Lovell into believing that if they just go with the midwives and the homebirth experience everything will be perfect and magical and everything that went “wrong” during the first birth will definitely not happen again.

        • Anj Fabian

          Exactly that. Caroline Lovell had a serious PPH with her first birth and was at risk for another.

          The midwives she hired
          (I believe they were IMs and therefore outside the system)
          never asked for her records, never obtained her records, never saw her records. IIRC, Lovell did tell them about her previous PPH, so they were aware and had motivation to look more closely but didn’t.

          Lovell had the lovely, supported, mostly hands off birth that she wanted. She did not get the care she NEEDED and that’s what killed her. She died because her midwives believed that birthy bullshit was enough.

          • Ozlsn

            And she died because no one in that room believed her when she said something was wrong and she was dying. Her husband and mother-in-law trusted the midwives who said she was having a panic attack.

            How the hell those two midwives escaped prosecution I do not know. They weren’t just incompetent but actively obstructive – the paramedics were told it was cardiac arrest so spent far too long trying to revive her rather than treating PPH, they disposed of the delivered placenta so it wasn’t available as evidence, they were evasive with medical staff at the tertiary medical hospital where Lovell eventually died.

            Honestly she might have been better off freebirthing because I think her husband and mother-in-law would have called the ambulance sooner.

          • Anna

            I know a couple of women that have realised without their midwives reassurance they were fine they would likely have transferred early enough to save their babies. Carolines midwives took the time honoured tradition of deregistering to avoid consequence. Then they get to be martyrs too.

      • AnnaPDE

        Yeah I didn’t really get that example anyway. Because let’s face it, the traumatic bit in having PPH and almost dying isn’t necessarily the part that the doctor or midwife is doing the painful maneuvre of stopping the bleeding and isn’t mincing words about just how serious the situation is.
        It’s the horribly scary fact of almost having died in the whole ordeal. And this kind of thing needs to be properly addressed afterwards, so the patient understands what exactly happened, why, and whether they need to worry about it happening again. Doctors get criticised all the time for not doing proper patient debriefing, and rightly so. I don’t see why it’s ok for midwives to not address such things either.

        • Ozlsn

          The debriefing needs to be available on request and long after the 6 week follow up appointment, whether that is through a dedicated clinic or through hospital-based counselling or however. I know I asked a whole lot of stuff about what happened and the odds of it happening again in my 6 week appointment and I remember nothing of what was said – I only know because I emailed my family some of the information and I came across that email much later. I had another appointment with an obstetrician where a lot of the same stuff was discussed two years later, and several years later again I got my hospital records from when I was admitted to look at what they said. I am dubious that this length and kind of follow up would be feasible through Dahlen’s care model.

          Having said that I think the team model where you have the same midwifery/obstetric team following you through the pregnancy is a good idea – as long as the two groups work effectively together. A lot of pregnancies are low risk until they aren’t, and having at least been introduced to the ob part of the team makes it at least a bit more familiar if things change. Also having two different people review charts might help catch a few people who are showing symptoms that are a bit unusual.

  • Alia

    Sorry if I’m a bit pedantic here, but Myanmar is not an African country, it’s in Asia.

    • Amy Tuteur, MD

      Thanks! Fixed it!!