Statistically, Australia is a very safe place to give birth, but the care families receive is a lottery. Three women who live less than 90 minutes apart had very different experiences, by choice, chance and necessity. Their stories reveal a complicated system crying out for change.
When Shikha Sahay fell pregnant for the first time in 2015, she had an experience similar to a lot of first-time mums: she didn't know much about maternity care.
"At that point, I didn't have many friends that had had babies," says Shikha, 36.
After researching her options, Shikha applied to be a part of the midwifery group practice program at her local hospital in Wollongong on the NSW south coast.
Midwifery group practice, or "caseload midwifery", typically involves having one midwife providing the majority of care through a person's pregnancy, birth and postnatal period. That midwife works as part of a small team offering the same kind of care.
"The most appealing thing was the continuity," Shikha says.
"To have that one person throughout that would know me, know my values and how I'd like to birth."
Shikha was assigned a midwife and enrolled in the hospital's homebirth program, hoping to give birth in a familiar environment with minimal medical intervention.
In the end, she went a fortnight past her due date, was induced and gave birth in hospital.
"Once I got to the hospital, I was so exhausted — I hadn't slept for a couple of nights," Shikha says.
"[Labour] wasn't progressing in the way it needed to for me to have an intervention-free birth."
Shikha had an episiotomy — an incision made to widen the vaginal opening during birth — and doctors used forceps to deliver her baby.
Having her midwife there helped Shikha feel safe and supported.
"It was amazing being able to have someone by my side that I had this relationship with.
"I would look to my midwife for approval — I had that much trust in her — and everything was my choice."
The maternity lottery
The option for Shikha to have one primary carer throughout her pregnancy, birth and postpartum period is something many expectant parents want, but relatively few can get.
Midwifery group practice programs — targeted at women with low-risk pregnancies — are only available at some public hospitals, and waiting lists are long.
"In many places around the country, you ring to book into a 'continuity of care' program basically when you've done your pregnancy test," says Caroline Homer, a leading midwifery researcher from the Burnet Institute.
"There are jokes that women book in before they tell their partners they're pregnant."
According to government figures, 31 per cent of maternity models in Australia offer full continuity of care. But maternal health experts say the proportion of women who can access those services is probably much smaller, which means many Australian parents are missing out on the best model of care.
Research shows that midwifery-led continuity of care models — including team-based midwifery programs — are associated with lower rates of intervention, lower risk of preterm birth and fetal loss, and higher rates of maternal satisfaction.
"Midwifery models all include referral to obstetrics when needed … but the principle is every woman needs a midwife she knows," Professor Homer says.
For those who can afford it, continuity of care is also offered by private obstetricians and midwives. Private maternity care is estimated to cost between $2,500 and $20,000.
But accessing continuity of care in the public system is a "postcode lottery" in terms of what services are available in your area, and a "knowledge lottery" in terms of knowing how to access them, Professor Homer says.
"Firstly, you have to know that such a thing exists, and then you have to know what to do.
"If you've got a good GP who's hooked into the system and who understands what's going on, then you're OK. But if you go to a big city GP, they may not know what's available."
It's even more challenging for women who are unfamiliar with Australia's health system, have low levels of health literacy, or for whom English is a second language.
In the public sector, some women access continuity of care by choosing to have a "shared care" arrangement with their GP, while others may see one health professional (or a small team) because their pregnancies are considered high risk.
But most expectant parents will see a succession of midwives and doctors during pregnancy and birth, which makes individualised care a challenge.
And for those in regional and rural areas, including a significant proportion of Aboriginal and Torres Strait Islander women, it's even harder to access maternity care that is close to home and culturally safe.
This is all reflected in the data: research shows the experience is tougher and outcomes are poorer for migrant women, women with disabilities, First Nations women, and those living in rural areas.
"There are still women who are not getting the models of care that they want or need, and not getting access to care that is in their community," Professor Homer says.
"We're seeing small towns closing services and women having to travel a long way, particularly in rural Australia."
Navigating birth education
Sarah Bushby, 31, lives in the outer suburbs of western Sydney, about 90 minutes north from the Wollongong area where Shikha lives.
Like Shikha, Sarah didn't know much about her maternity care options before becoming pregnant with her first son Luca, who was born just 10 weeks ago.
After seeing her GP, Sarah enrolled in her local public hospital's general maternity program, but was assigned a single midwife — for her pregnancy, but not her birth — who looks after women with more complex health needs.
"I was part of the general midwife group, but I did see the same midwife the whole time because I'd had [gastric-sleeve] surgery," she says.
"It was good having the same midwife, and not really having to repeat myself and have someone different look at my file."
When Sarah went into labour, she developed pre-eclampsia — a pregnancy complication characterised by high blood pressure — and after a long labour, agreed to have an emergency C-section.
Despite a slow and difficult recovery from surgery, Sarah says her experience was better than she'd expected.
"From what I'd read and heard, hospitals seem to have kind of a bad rap — people saying they felt pushed into doing things or felt they didn't have any other option," she says.
"But that really wasn't my experience.
"From the time I got to the hospital when my waters were broken to the time I left, [the medical staff] were amazing."
One of the main challenges Sarah encountered was trying to navigate vast amounts of pregnancy and birth advice online.
"There's a lot of information out there available … and there are so many different people that have different opinions," she says.
"I found it quite confusing … and I'm sure that other mums would be feeling the same."
The politics of birth
In Australia, discussions around birth have become increasingly polarised, and there are significant differences of opinion among healthcare professionals.
"When you look at the statistics, Australia is a very safe place to give birth, but there are pockets of problems," Professor Homer says.
According to critics of the maternity system, these include record-high rates of medical intervention, a growing chorus of women reporting birth trauma, and a lack of unbiased antenatal education.
Advocates for maternity reform argue that increasing rates of intervention are being driven by a risk-averse medical culture and that women are sometimes left feeling coerced.
But obstetricians tend to disagree. Many argue that birth is safe in Australia largely because of obstetric care, and that extolling the virtues of "natural birth" downplays the risks.
In 2020, 37 per cent of women in Australia gave birth via C-section and almost half of first-time mums were induced.
Both those rates have roughly doubled in the past two decades.
Health economist Emily Callander from Monash University says increases in intervention are pushing up costs for the health system, with little improvement for parents and babies.
"We're seeing very rapidly increasing rates of caesarean section birth and induction of labour, but we're not necessarily seeing that translate into declining rates of adverse outcomes."
On the other hand, the changing face of birth in Australia can be partly explained by the increasingly complex needs of pregnant women, according to the president of the Royal Australian College of Obstetricians and Gynaecologists (RANZCOG), Benjamin Bopp.
"We have a different population having babies to what it was 20 years ago," says Dr Bopp, who works as a public obstetrician on the Gold Coast.
"[It's] an older population, a population more likely to be overweight, with more comorbidities."
Concerted efforts to reduce the rate of stillbirth are also playing a role, he says.
Six babies are stillborn in Australia every day, though the rate of late stillbirths (beyond 28 weeks' gestation) is decreasing.
"A lot of that involves intervention, when necessary, particularly with things such as reduced fetal movements," Dr Bopp says.
And more women are choosing a caesarean birth, he adds, because they are mindful about the risks of vaginal birth.
"There's been much more awareness over the last 10 years of the lifelong consequences of pregnancy and childbirth, particularly pelvic floor damage and … issues with incontinence or prolapse.
"In the world of obstetrics, there's a large call for reduced intervention. But by the same token, there's also a call for increased intervention.
"What's important is individualising treatment plans, and discussing with women and their families which way they want to progress, because it's the patient's choice as much as it is our advice."
Going private
When Jaimi Gallagher fell pregnant in 2021, she already had some knowledge about what kind of care she might want.
As a physiotherapist working in women's health, she often cares for women during their postpartum period and hears about their experiences of pregnancy and birth.
The most important thing for Jaimi, who lives about an hour from Sarah in Sydney's beachside suburbs, was knowing who would deliver her baby.
"Being able to choose someone that I trusted, who was knowledgeable and experienced, and to have them consistently through my care … was really important."
Jaimi also believed she'd be at an increased risk for complications for a few reasons, including that she'd injured her pelvis in a car accident.
After much consideration, she decided to have an elective caesarean — and opted for private care.
The birth was scheduled between Christmas and New Year's Eve, when Jaimi was 39 weeks along.
During the birth, a sheet was put up between Jaimi and her belly while the doctor made the incision, but Jaimi asked for it be taken down so she could see her baby being born.
"Then he lifted her out and I got to announce it was a girl because it was a surprise," she recalls.
"It was really, really special that I got to see it … I was so happy and just elated and very, very overwhelmed with emotion."
Jaimi says she feels deeply grateful to have had the choice to birth the way she wanted.
"It absolutely should be up to the individual how they give birth, and I think it's different for every woman.
"I know that [my decision] is not the right decision for everybody, but it was the right decision for me and my body … so I can be the best mum I can possibly be to Grace."
Transforming maternity care
When it comes to expanding continuity of care models in the public system, Dr Bopp says RANZCOG supports "any increase in access to safe maternity care and choices".
"The issue is resources," he says. "It's workforce, it's financial.
"There are significant shortages in midwifery across Australia and New Zealand, so continuity of care in the public system is a challenge.
"I think if governments were serious, they'd be putting a bit more money and a bit more time and effort into it, but there's a whole range of priorities that public hospitals and health services have to deal with."
According to Dr Callander, midwifery-led continuity of care models are no more expensive than standard models of care.
She says expanding such models is also a way to potentially improve the retention of midwives, and meet growing consumer demand.
"Quite a high proportion of midwives say they're feeling disillusioned and not empowered to actually work their full scope of practice," she says, "whereas midwives working in continuity models report very high levels of satisfaction."
Professor Homer says there's no reason why Australia can't redesign its maternity services — especially antenatal clinics — to enable every woman to be cared for by one or two midwives, and when necessary, one or more doctors.
"The reason why it hasn't been implemented? It takes hospital redesign, and hospitals are hard places to redesign," she says.
A statement from the Department of Health and Aged Care said it was "committed to improving health outcomes for women and their babies".
"The Government will continue to work with women and stakeholders on how to further strengthen appropriate antenatal care and other maternity services, including expanding the availability of continuity of care and carer models to enable women's choices to be met."
Birthing at home
Three years after their first son Dashiell was born, Shikha and her partner Louie welcomed two more children — Sugriv in 2018, and Jubilee in 2021.
Shikha says they were "incredibly lucky" to be a part of the same midwifery group practice program both times, particularly during her second pregnancy when she saw the same midwife as the first time around.
"We already had an established relationship, so she knew what I wanted," Shikha says.
With the support of her midwife, Shikha was able to birth her two younger children at home.
"It was everything that I had wished for."
Shikha says it's important her older children were able to be part of it.
"Watching us become a family of five together — that's really powerful, and such a beautiful bonding experience for them."
Despite having a very different birth to Jaimi, Shikha shares her gratitude for having choice in her birth, and a hope that more women get the same.
"For me, your birth is your own. So, whether you choose to go public, private, homebirth, natural birth, all the things… that's completely up to you.
"There is no one right way to birth — and that's just how it should be."
The ABC wants to hear your stories about birth and maternity care.
Visit The Birth Project to find out more.
Credits
- Words and reporting: Olivia Willis, Kathleen Calderwood
- Photos: Stephanie Simcox
- Editing and production: Joel Zander
- Birth Project producers: Emma Morris, Rhiannon Hobbins, Flip Prior
