Choosing a care provider

Aug 19, 2019

Doula Caesarean Midwife Homebirth

Natural unassisted birth

If having a natural unassisted birth is incredibly important to you, perhaps you should consider engaging the services of an independent or private Midwife and plan for a home birth. Research consistently shows that statistically you are much more likely to achieve your goal of an unassisted vaginal birth if you give birth at home. Research that looked at all births in Victoria, Australia from 2000- 2015, showed that for healthy women without any complications or high risk factors, planned homebirth with appropriate supervision is a safe option and is associated with lower rates of epidural, episiotomy and unplanned Caesarean Section. And higher rates of spontaneous vaginal birth.1 However, if you have any high risk factors such as: a previous caesarean (or uterine surgery), a multiple pregnancy, 5 or more previous births, a presentation other than cephalic in labour(i.e. The baby is not lying head down), maternal obesity, or significant maternal medical condition. Or even if your home is a long way from a hospital to which you could be transferred in an emergency, then this may not be the safest option for you or you baby. Only 0.3% of births in Australia in 2017 were homebirths.2 But in other countries the statistics are much higher, around 4% in New Zealand.

Some costs might be partly covered by private health insurance, some might be Medicare funded. The average cost of a private midwife is around $3500-6000. This includes, pregnancy, labour and up to 6 week postnatal care. Other costs such as the hire of a birth pool will usually be in addition.

Hiring a Doula

If an unassisted birth is still your preference but a homebirth is not, then perhaps you might consider hiring a Doula. A Doula is someone who is paid to support you during labour. They are not responsible for your care, but act as a social support. They are often mothers themselves, and have training in how to help you achieve the birth you want. Some people choose them to help guide them through this unknown territory. Research shows that women who have the support of someone they trust in labour will on average; have shorter labour’s, less medical intervention and increased feelings of being in control of their pain. This support may be provided by anyone, but a Doula can be the extra support when perhaps your partner or family feel they are out of their comfort zone.

A good Doula can be a good emotional support as they won’t be anxious of what’s ahead. They can help guide you and your partner to make choices, remind you of different options to consider at the time. They can provide practical help, giving massages, providing snacks, allowing your partner to take a break, being the liaison between you and family who aren’t present, but keen to know how it’s going. Some Doula’s can support you at home as early labour begins, and then accompany you to the hospital, some offer post-natal support too. A Doula can be a reassuring presence that allows you to go with the flow and trust in the process. It’s important for you to know that this is also the role of the midwife, the difference being that you can know your Doula in advance and can be sure that you share the same values around childbirth, also hospital midwives are constrained by their working hours. You may have struck up a wonderful relationship and feel incredibly supported, but they are not permitted to work beyond their allotted shift, so although the next midwife might be just as fantastic, they are still someone new. A Doula may charge between $500 and $2500 depending on what services they offer.

Public or private

If you think having an unassisted birth would be your preference, but you are aware that our plans don’t always go smoothly, and would like several options available to you, then you should think really carefully about your chosen sector; public or private. Research shows the statistics for how often this is achieved in each sector. Of all births in Australia between 1998 and 2007, in public hospitals, 28% were caesareans, in comparison to 42% caesareans in the private sector.3 That’s almost half of all babies born in the private sector. Statistics alone should never be taken at face value. There is no way of knowing the individual circumstances involved behind these numbers but it’s interesting to note that there is a particular obstetrician in Melbourne with the nick name ‘Vaginal Lionel’, it might be prudent to consider why this is unusual among the vast cohort of Private Obstetricians?

When you choose to have a baby in the public sector there are often more limited options available to you. You may not be able to choose your preferred hospital, but instead be assigned to your nearest. You may not see the same doctors or midwives each visit. Although many hospitals have some variation on small teams of midwives. If you and your baby are well, without complications, you may rarely see a doctor. If you have a medical condition, you may well see the same doctor on each visit, (the chances of this are increased if you booked your appointments at the same time and day of the week each time). In a hospital setting it is usually a midwife who will help you to birth your baby with no doctor present. When there are no complications present, pregnancy and birth is considered a normal life event rather than an illness or a medical condition. Many women and families aren’t aware that in most instances unless an instrumental birth is required a doctor will not be present for the birth. Midwives are highly trained in caring for women during pregnancy and birth. If complications arise a doctor will now be responsible for your care, but the majority of your care will be provided by a midwife.

One huge benefit in a public hospital is that if a serious emergency or complication arises there are numerous doctors and specialists instantly available for you, as opposed to waiting for your one doctor to arrive. If you require an epidural an anaesthetist will be available to insert it, but once again, a midwife will be caring for you at this time. If you require a C-Section an experienced team should be available at all times. After your baby is born, you are not guaranteed a single room and may have to share. You may possibly have the option of being discharged early and have an extra home visit from a hospital midwife.

In the public sector you will not be charged for most expenses such as; your antenatal appointments, some scans and tests, hospital stay, anaesthetist services, and paediatrician services, physio services, lactation consultations, as they are covered by Medicare. Although some expenses like Ultrasound scans, blood tests, childbirth education classes may be externally sourced and a charge will be incurred.

Planned caesarean

If you are someone who knows that they will need a planned caesarean (C-Section) for medical reasons, or perhaps it’s the only way you can even contemplate having a baby, then choosing a Private Obstetrician might be the best option for you. There are (as always) lots of things to take into consideration when making this choice.

In the private sector having a baby can cost around $10,000-30,000 without insurance cover. If you have medical insurance most providers regard maternity/pregnancy/obstetrics, as an ‘optional extra’ meaning that you will have to include it in your policy in advance, and usually pay an increase to your premium. Most policies have a waiting period of at least 12 months before you can claim any pregnancy related expenses. Even with insurance you need to check what inclusions apply. Some policies don’t cover obstetric care or midwifery care. Some don’t cover a portion of the hospital fees. Some don’t cover your baby (you may be charged separately for nursery care), private anaesthetist services, private paediatrician consultations or a second twin, or multiples. Some of the expenses not covered by your insurance may be able to be claimed on Medicare.

Usually if you go into labour before 32 weeks of pregnancy you will be transferred to a public hospital with a neonatal intensive care unit (NICU), if this happens you will not incur any costs as it is covered by Medicare, but your obstetrician will no longer be responsible for your care. On average, out of pocket expenses might come to around $3000-8000. You could ask your doctor for informed financial consent, meaning that the set charges are agreed upon in advance. This should include what are the charges should unexpected complications arise.

Another possibility is to opt for a private obstetrician in a public hospital. Although not all obstetricians offer this service.

With a few private hospitals there is the possibility of enjoying the benefits of a partnership with 5 star hotel in the area. This service is at the discretion of your obstetrician and also availability, and is therefore not guaranteed. After you have your baby, you, your baby and partner will be transferred by chauffer to the hotel. During your stay you will have the luxury of room service whilst being under the care of a midwife

Which is better public or private?

In a country with a fantastic health care system such as Australia, you might want to consider that in terms of quality of care one option is not universally preferable to the other. The difference boils down to having a greater element of choice when you choose to engage the services of a private obstetrician. In Australia in 2017 just over 304,000 babies were born in Australia. Approximately 23% of these were in the private sector.4

Firstly consider what are your reasons for choosing to ‘go Private’?

• Is it simply that you want to be familiar with the person who will deliver your baby? What if circumstances arise which means they can’t be there on the day?
• Has someone recommended them because they are easy to talk to? Does this mean they will share your philosophy around birth?
• Do you believe that because it costs more it must be better? The same doctors have all come through the public system, and often still work there.

Many people don’t really have a grasp of how the system works and what they are getting for their money. The most frequent phrase I have heard from people explaining their choice for a private obstetrician is, ‘We wanted the best possible care for our first baby’. Believing that the more expensive something is then it must be better. However, that is not necessarily the case. All obstetricians in Australia have to be registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, RANZCOG. All Obstetricians follow the same strict professional education program to be registered with RANZCOG. They have all come through the public hospital system gaining knowledge and experience and passing the same rigorous exams. Private obstetricians don’t have any ‘extra’ ‘or ‘superior’ training, and many choose to combine employment in the public hospital system at the same time as having a private practice. Which is to say that privately-paid obstetricians are not of a superior caliber to public hospital Consultants, they’ve just chosen to have more autonomy over their working lives.

Private obstetricians

The main advantages of a Private obstetrician is that you get to know them over multiple antenatal appointments. You develop a relationship and you don’t have to continually divulge the same, possibly sensitive, information to multiple health professionals on subsequent visits. However, when it comes time for baby to be born it may not be possible for your Doctor to be present. In all hospital settings private or public, a midwife is assigned to look after your care. They are trained in all aspects of normal birth and have personally been the accoucheur (person who delivers the baby) for many births. A midwife will be the person who will be with you throughout. The doctor will most likely only pop in for a quick visit, perform some assessments and be kept updated by phone as to how things are going. They will be responsible for making decisions, but often remotely if everything is going well.

Consider these possible scenarios; it’s 11 a.m. on a Wednesday morning and your doctor is in antenatal clinic with their other pregnant patients, in one of the satellite clinics that it was so convenient for you to attend. You are in the hospital and you unexpectedly start to push. On this occasion, if they drop everything to be with you, they may arrive in time to congratulate you on the smooth and easy birth of your baby, (in which case they still get paid even though they didn’t deliver your baby). Alternatively, they may be there in time for the birth, walk in and catch the baby and leave. Another alternative might be; they may also drop everything and get to you but the baby hasn’t been born yet. You have been fully dilated (ready to push) for 20 minutes. Perhaps the baby’s heart rate monitor (CTG) reading is not quite optimal (it rarely is at this stage of labour). Realistically, how much time has the obstetrician got to hang around the labour room? They have a clinic with multiple appointments to finish then perhaps some surgeries scheduled for the afternoon? What are the chances that they seek to expedite your birth rather than wait and see how you progress? It may be very dependent on what else they have to be doing at the same time. Or what if the CTG shows the baby is in distress and needs to be born urgently but the doctor isn’t even in the building, or perhaps he/she is but is in the middle of another operation? These events aren’t likely to occur often, but something you should consider, and maybe ask you potential doctor what their contingency plans are for similar scenarios?

If you find part way through your pregnancy that you don’t feel comfortable with your obstetrician it’s OK to choose a new one. It’s your baby and your birth, you really should be happy with your care provider. They too have your best interests at heart and ultimately it’s a business transaction you’ll be terminating, not a friendship. You may be too late to engage another private obstetrician but a public hospital will see you.

How to choose a private obstetrician? Doing your research is so important to make the right decision for you.

• Which hospitals does your preferred obstetrician work at?
• Do they have satellite antenatal clinics in convenient locations, as in, near your place of work or home?
• Will they be available for all antenatal appointments and the birth?
• What hours are they available to be contacted for questions?
• Do they have a shared group option (where a small group of doctors cover each other’s patients care in their absence), who are they?
• Do they have extensive knowledge in a specialist area e.g. multiple births, endocrine disorders.
• Do you feel able to freely discuss your birth preferences?
• Are their philosophies and practices compatible with your expectations?
• What are their statistics, ratios of emergency C-Sections, compared with instrumental births and unassisted births?
• Do they have upfront payment agreements, so you have an idea of possible costs?

Ambulance cover

Whichever option you choose, always make sure you have ambulance cover, particularly when pregnant or with a young family! Without it a short trip to the hospital can cost around $1000 in an urban area, $2000 in regional Victoria and approximately $26000 if you needed a helicopter ride to hospital. Family ambulance cover in Victoria costs less than $100 a year.

So remember whilst there are many options available to you, everyone involved is invested in helping you to achieve the outcome of a healthy baby and a healthy Mum. The way in which you choose to go about it is going to be individual to you, so what might be right for your friend or sister or mum may not be the best fit for your unique circumstances.

---

1. Planned private homebirth in Victoria 2000–2015: a retrospective cohort study of Victorian perinatal data. Miranda L. Davies-Tuck, Euan M. Wallace, Mary-Ann Davey, Vickie Veitch & Jeremy Oats
2. Australia’s mothers and babies 2017—in brief
3. Australia’s mothers and babies 2017—in brief
4. Australia’s mothers and babies 2017—in brief