If you’ve ever seen, or been involved in, a discussion about birth plans, you’ll know there’s always someone who says there’s no point having a birth plan, because you can’t plan a birth.
It’s true that birth can be unpredictable.
However, many aspects of maternity care are not currently working in our favour.
Some, in particular, actually sabotage women’s potential to birth normally, with minimal intervention.
For as long as I’ve been working in the birth industry, Australia’s birth outcomes have shocked me.
Two outcomes are of particular concern.
C-section rates are around 33% and are creeping higher. This means 1 in 3 babies are now born via major surgery.
More recently, an obstetrician shared another statistic: in a large public hospital, around 50% of first time mothers have inductions of labour, and many of them go on to have c-sections.
Even medical professionals are beginning to take a serious look at what’s going wrong.
As you might guess, the root cause of these rates involves any number of issues. It’s a combination of quite a few things that we haven’t yet got right.
One of the most unsuspected, yet significant, reasons why birth is going off the rails in Australia is hospital-based birth education.
Hospital-Based Birth Education – A Wolf In Sheep’s Clothing?
There is no requirement for hospital-based birth classes to adhere to any set standards.
Neither is the content required to be evidence-based, or monitored by any organisation.
Therefore, hospitals can do whatever they like in their own birth classes.
Although there are some great hospital-based birth classes available, a number of midwives I spoke to have described some hospital-based classes as “shocking”, “inadequate” and “horrifying”.
I spoke to some experienced, practising midwives who had experiences in different hospitals. I asked them what they thought of hospital-based birth education.
One midwife, who wished to remain anonymous, said:
“I’ve known several committed, passionate midwives who teach enriching and empowering birth education classes. However, when a woman arrives in the labour ward and contests the intervention advice, the same passionate midwives are bullied out”.
She continued, “Even within a birth centre, I found that their class content was surveilled and the material censored. So, if you really want to understand childbirth, don’t do hospital classes. And be cautious when these classes are recommended by your doctor or hospital. Affiliation with standard maternity care guarantees the classes will be corrupted”.
I spoke to another midwife, who also wished to remain anonymous, who recalled being removed from teaching childbirth classes in a public hospital in Melbourne, some years ago.
When she presented the classes, she discussed the downside of using pethidine for pain relief during labour.
The midwife was reported to management after a labouring woman questioned the suggestion of pethidine.
Has hospital-based childbirth education become “a giant orientation program to ensure patients are compliant to a system’s needs?”
Hannah Dahlen*, Professor of Midwifery and Higher Degree Research Director in the School of Nursing and Midwifery at Western Sydney University, believes so.
She also questions whether midwives employed by organisations are the most appropriate providers of birth education.
Evidence That Hospital-Based Birth Classes Need A Major Overhaul
Professor Dahlen recently co-authored a study designed to compare the outcomes of hospital-based birth classes with results from an education program that included topics explaining how women could work with pain, using natural methods.
The program gave women and their partners more ‘tools’ in their toolbox, to equip them to better manage labour pain.
Here are the dramatic results for women who undertook the education program:
- Significant reduction in epidural rates, compared with women in the control group (23.9% vs 68.7%)
- Reduced caesarean section rate (18.2% vs 32.5%)
- Significantly less likelihood of labour needing to be accelerated using artificial means (28.4% vs 57.8%)
- Less likelihood of perineal trauma (84.7% vs 96.4%)
- Shorter second stage (pushing stage) of labour (mean difference of 32 minutes)
- Babies were less likely to require resuscitation (with oxygen and/or bag and mask) at birth (13.6% vs 28.9%)
Why Was There Such A Dramatic Difference?
“I think one of the risks you run in having classes from within an organisation, run by an organisation, and given by people who are employees of an organisation, is they can have a tendency to toe the party line, and perhaps give information to women and their partners which is about making sure they conform to the requirements of the organisation and not the needs of the individual woman and her partner. And that concerns me”, Professor Dahlen explained.
“There are excellent childbirth educators in some hospitals across Australia, but the system makes poor practice go unchecked”, added Professor Dahlen.
I also spoke to the study’s lead author, Doctor Kate Levett.
Doctor Levett said, “Hospital based education is parent education, and covers a broad range of topics. However I don’t think it’s adequate birth preparation. Often, it focuses on what the hospital does, what it expects, and what its protocols are, without considering the evidence. A recent US study showed unit management and workflow procedures had the biggest influence on the mode of birth.
“The system doesn’t support physiological birth preparation and prepares women for ‘if something goes wrong’, focusing on medical supports. The study found that when women and partners understood physiological birth and had adequate preparation, they came to view medicine as a back up, if needed, not as the first line of support. The couple needed to have their own tools and ways to support themselves during birth”, she continued.
When Hospital-Based Birth Education Goes Bad
In my years of experience, I’ve heard many negative stories about birth education.
What Professor Dahlen shared with me, however, took things to a whole new level. Hearing her share these women’s stories made me feel sick to my stomach.
“What we were quite horrified by, when we undertook the trial, was that we interviewed women and their partners about their experiences, and some of the stories I heard – what was being said in the parent education classes – I think was pretty scary.
I’ve also heard stories from midwives working in private hospitals, where there is a set slideshow, and they are not to deviate from it; they are not allowed to mention certain things [for example, waterbirth], and if they do, they are quickly replaced”.
She added, “I think there’s a way that the organisation can make sure the needs of the organisation are looked after through a parent education class… we’ve lost sight of what parent education was all about.
By the 1990s, the focus of childbirth education classes shifted from natural childbirth preparation to hospital birth preparation, with a focus on medical interventions, such as such as pharmacological pain relief, induction of labour and caesarean sections”.
Horror Birth Education Classes
While reviewing interviews for the study, Professor Dahlen heard many stories.
This was one of the worst, and most deeply troubling.
It’s a perfect example of the terrible things that slip through an unregulated area, and go unnoticed.
The woman she interviewed had attended birth classes in a public hospital in Sydney.
This is what happened in the classes:
The presenter had partners dress up in theatre gowns so they would feel comfortable (if they went into theatre).
Then, on the table in front of them, they had a number of cards that contained choices and options for birth – for example, waterbirth, breastfeeding, bonding, c-section, forceps etc.
Each couple would then take away the cards they could most live without. The first to go would be things like waterbirth, upright birth, no pain relief…
Eventually they were left with one card – a live baby, because that was obviously a non-negotiable thing they couldn’t live without.
Then the presenter would say, “See! The most important thing is here”.
Professor Dahlen says she finds this horrific and really scary. Subliminally, it says says to women and their partners: ‘You must surrender everything if you want a live baby… it’s all that’s important. You are irrelevant, and unless you surrender everything else, you could lose the one thing that is most important to you’.
And, which is interesting to note, the only reason anyone found out this was happening was because this woman was interviewed for the study.
Another disturbing story I heard came from independent birth educator, Katie Kempster.
“A recent client who attended my classes had also taken hospital-based classes in a public hospital. She told me that the educator had set up a bed with stirrups, then asked the room of 12 or more pregnant couples which mama would like to jump up in front of everyone and demonstrate how to lie flat on your back and practice getting into the stirrups,” Katie said.
Going Private Doesn’t Mean You Get Better Quality
There are issues with birth education in private hospitals too – it’s certainly not always the case of getting what you paid for.
For example, in some private hospitals, waterbirth is basically banned, but many women do not even realise it. They bring up the subject with their obstetricians, closer to the birth, only to be told they can’t have one.
Professor Dahlen says sometimes the obstetricians will front up to management, and ask for requests for waterbirths to be ‘dealt with’. Management will then confront the midwives, who are then forced to comply with the hospital’s approved content, or face being removed, and unable to offer any education.
As one midwife anonymously observed, “A hospital’s most important customer is not the woman and her partner. It’s their doctors. More so in private hospitals than public, but for different reasons”.
Pip Owen is a trained midwife, who used to teach pre-natal classes in a private hospital.
She said, “I was ‘reprimanded’ and had obstetricians not ‘allowing’ women to come to my classes. This is why I decided I had to become an independent childbirth educator (CBE). I strongly believe childbirth education should always be independent. I’m not a fan of hospitals providing “alternative programmes” either, and I really worry about health fund endorsed programmes. I also don’t think just because you’re a midwife, you’re a good educator, because I have learnt far more from my training as a CBE than I ever learnt through my midwifery studies. I really think a CBE qualification should be compulsory [for those teaching childbirth education].”
Of course, no industry is ever perfect. Professor Dahlen says that although hospital-based education has its problems, everything isn’t smooth sailing in the independent education sector either, with in-fighting and competition being the key destructive elements.
The Biggest Surprise From The Education Study
I asked Doctor Levett what she found to be the biggest surprise as a result of the study.
Referring to dads-to-be in the education group, she said, “The biggest surprise was the influence of the partner. It was a real team approach. And the value of labour support was key. A partner enabled a safe space, where the woman could go into the zone, using breathing, visualisation, active positions and water; the partner supported her with tools like massage and acupressure. It was about understanding the natural physiology and not being scared of it”.
She added, “There is an obvious shift at the end of the first day, when the partner has enough physiological information and gets the philosophy and the benefits of normal birth. The woman then visibly relaxes and can go into herself to get ready and prepare”.
Although Doctor Levett didn’t have much contact with the control group in the study, she said, “We did an interview with one husband who didn’t actually attend. It was a stark contrast. There were comments like, ‘It doesn’t matter how the baby gets born, just so long as it’s healthy’. That attitude seems prevalent. It’s very much medical and hospital discourse. But the messaging is strong. In the focus groups, the midwives reported that partners can make or break it”.
Don’t Leave Your Birth To Chance
I asked Doctor Levett what advice she would give to parents considering birth education.
“Get educated about your options. Know your rights. Have tools and knowledge to support physiological birth and the way your body works”, she said.
So, if you want to have a birth with fewer interventions rather than more, it’s not wise to pin all your hopes on hospital-based birth classes.
Instead, it’s essential you seek out independent birth education.
Every midwife I spoke to recommended independent education, even if it’s in addition to your hospital-based classes.
*Disclaimer: Professor Hannah Dahlen receives no funding for nor endorses one particular method of childbirth education.