Sunday spam: muesli bars and gummy snakes

Muesli bars and gummy snakes are what I ate at about 7am before my recent 9am childbirth… thus thematically appropriate for this small collection of links, some of which I’ve had sitting around for a while.

Using WOC in the Natural Childbirth Debate: A How-To Guide.

If you are a progressive in the Natural Childbirth Movement (or any other, for that matter), use Africa City women to promote the idea that “natural is better.” Talk about women who toil in the fields, squat down to give birth and return to picking rice. Or peanuts. Or anything else that can be picked. After all, the women of Africa City are resilient! Strong. So strong that they do not even require support from the other women of Africa City. Or medication. Or comfort. This example–of giving birth in the field–illustrates how over-reliant “we” have become on useless technology. Of course, you don’t expect “us” to be quite that strong. We are not beasts of burden, after all…

If you oppose the Natural Childbirth Movement (or any other, for that matter), use Africa City women to remind “us” of how bad “we” used to have it, before all of our live-saving medical advances. If women die in childbirth in Africa City, it is only because they lack the Modern Technology we should be grateful that every last one of “us” has unfettered access to. Use infant mortality statistics from the most war-torn countries to argue why a healthy woman from Portland shouldn’t give birth in her bathtub with a midwife who carries oxygen and a cell phone. Redact all mentions of Africa City women who are not hopelessly impoverished. Ignore those who are systematically abused with Modern Technology, sacrificed as Guinea pigs on its altar. All bad outcomes in Africa City are due to the lack of Medical Technology, never unrelated to it, and certainly never caused by it.

Early Labour and Mixed Messages

The emphasis on hospital as a place of safety whilst also encouraging women to stay away results in some very contradictory messages and ideas (please note these statements do not represent my own views)[…] We are the experts in your labour progress, our clinical assessments can predict your future labour progress… we will send you home if you are found to be in early labour… if you then birth your baby in the car park it is not our fault as birth is unpredictable[…] This is a safe place to labour…. but you can only access this safety when you reach a particular point in your labour… preferably close to the end of your labour i.e. you should do most of it on your own away from safety.

Warning for discussion of pregnancy loss. The Peculiar Case of Miscarriage in Pop Culture

Miscarriage is a tricky cultural thing, pop culture or not. It’s a deeply forbidden subject, much like many other things deemed ‘mysteries of womanhood,’ like menstruation, like pregnancy itself. People don’t talk about miscarriages and that discouragement means that many people aren’t aware of how common they are, let alone how devastating they can be. When people lose a child, they can reach out to their community for help and they are given space and time for healing. When they lose a fetus, they’re expected to keep it to themselves.

Sadly, sometimes pro-choice people can be the most vehement about this, concerned about blurring the lines between fetus and child, and saying that claiming a fetus is morally or ethically equivalent to a fully-developed, extrauterine human being could be dangerous. This makes the mistake of applying broad strokes to the issue, though. Legally, of course, a fetus should not be equivalent to a child. Personally, however, losing a wanted pregnancy is an intensely emotional experience and it can feel on some level to the parents like losing a child, with the added burden of not being allowed to acknowledge it, talk about it, or ask for help.

Should you give birth privately?

A few people have been researching their options over the last few years about giving birth in Australia, and have asked me what I think about having private health insurance or giving birth in a private hospital.

Background: maybe you shouldn’t ask me! I’m not a health professional, I’m a mother of one, and he was born in a public hospital, in which I was a public patient.

And now, crucial fact about private hospital cover: it pays much of your hospital stay fees and some of your doctor’s in-hospital fees. It does not pay for private consultations with a doctor in an outpatient/private room setting.

You know what obstetricians charge a lot for? The “pregnancy management” fee, to cover your outpatient care in pregnancy. If I recall correctly, the Medicare rebate for this is on the order of $400 to $500. In Sydney, private obstetricians may charge upwards of $4000 for this fee. Who covers the difference? You do. (OK, full disclosure, the Medicare Safety Net may help too, I don’t know the details except that MSN actually cut benefits specifically for obstetricians a few years ago because they’d all upped their fees to incorporate the MSN rebate. So, mostly you do!) Also, anaesthetists in the private hospitals usually end up with a decent gap fee, if you have an epidural or Caesearean.

So, private system birthing is expensive regardless of insurance.

Finally, tests like ultrasounds are usually Medicare plus out-of-pocket too.

Now, birth choices in Australia.

Homebirth. There are some very small number of hospitals in Australia that will allow their midwife staff to attend some homebirths. It’s very easy to get disqualified from such a program. I would be on several grounds (some more legit than the one I’m about to give you), including the simple fact that my son’s birthweight was over 4.0kg.

You might also birth with a privately practicing midwife, or, in theory, with a private midwife collaborating with an obstetrician as backup (there are very few such arrangements so far). Most, although not all, private midwives will also only work with pretty low-risk women (singleton pregnancies, head-down, no high blood pressure or diabetes, that sort of thing, about 80% of pregnancies get a low-risk classification IIRC).

Is private insurance useful? Some private health funds provide some limited cover for this, I believe, on the order of $1k to $2k of the midwife’s fee, which is around $5k last time I looked. In the collaboration setup Medicare contributes too, I think?

Birth centre These are midwife-only maternity units attached to public hospitals. (Sometimes at some physical distance, eg Ryde Hospital only has a birth centre, with transfers to Royal North Shore several suburbs away.) You need to be assessed as low risk and if that assessment changes (and this isn’t uncommon, eg, your baby is breech or you get diabetes or pre-eclampsia) you get summarily transferred to the doctors and your whole care team often is suddenly switched out from under you. (Also they usually don’t do epidurals, I think? So the transfer rate for pain relief is not insubstantial I believe.)

Is private insurance useful? No, this is publicly funded.

Public hospital, midwife’s clinic If you go to a public hospital, and are assessed as low risk, almost all of your pregnancy management will be by midwives. Often they “caseload” now, meaning you see the same one each time. Again, if you become high risk, swish, off to the doctors.

Is private insurance useful? No, this is publicly funded.

Public hospital, doctor’s clinic. If you aren’t low risk, this is you. (This was me.) Chronic health problems or pregnancy complications (like pre-eclampsia) put you here. For your appointments, or at least most of them, you see an OB registrar or staff specialist. On high rotation, often, that is, you won’t usually see the same one many times. If you have a vaginal birth it may still be midwife-only, or largely midwife managed.

Is private insurance useful? No, this is publicly funded.

Public hospital, private doctor’s patient. In this case, you choose your doctor, see them mostly in their own clinic, birth in a public hospital (with you or your private insurer paying for the facilities) with the doctor of your choice attending. This is subject to gap fees for the doctor.

Is private insurance useful? Yes, pays for your accommodation and some of the OB’s and anaethestist’s (if needed) gap.

Public hospital, private midwife’s patient. This depends on a midwife/obstetrician collaborative practice. As I said, rare, but there’s at least one that allows a public hospital birth (private admission) with the midwife of your choice: Melissa Maiman in Sydney.

Is private insurance useful? Yes, pays for your accommodation. Not sure what happens if an OB and/or anaethestist are needed.

Private hospital, private doctor’s patient. There’s no midwife-managed option. If you’re birthing in a private hospital, you need a doctor of your choice attending. Again, pre-birth consultations in their own clinic, and subject to gap fees.

It’s definitely worth noting that while your private doctor will be an obstretrician and can manage higher risk pregnancies, for really serious stuff like prematurity earlier than a certain point, pregnancies with more than 2 babies on board (I think) and similar, they will actually refer you into the public system!

Is private insurance useful? Yes, pays for your accommodation and some of the OB’s and anaethestist’s (if needed) gap.

Public hospital, high risk clinic. I don’t know much about this, I’m told it’s the next level up in risk, and it well might be my next pregnancy. Joy. This is where you end up with OBs with a high risk interest, maternal-fetal medicine specialists (OBs with a formal subspecialty in very high risk pregnancies), renal physicians, endocrinologists, etc. This often involves referral to a tertiary hospital. (Sometimes specialists can consult without you being in one of these, like, an endocrinologist might monitor diabetes or thyroid hormones with you in the regular doctor’s clinic or seeing a private OB.) Birth choices guides don’t talk about this option very much, because you don’t really have a choice at this point (except birthing unattended or with a very risk-tolerant private midwife).

Is private insurance useful? I’m not sure, to be honest. It probably depends on the risk profile of your actual birth, I guess? If your birth is able to be attended by a regular private OB, maybe they let you do this? But you can do this publicly too.

Further reading on birthing choices
My Birth has a lot of information on birth procedures and the outcomes of different birthing providers, from a low intervention advocacy standpoint. One thing of note which gets picked up a lot by low intervention advocates is that despite the private birthing system referring all their hardest cases back to public, and despite the public patient profile being poorer with less good preventative health care and so on, private hospitals have much higher intervention rates.

Conclusion

It really depends on where you want to birth and with who attending. If the idea of the same doctor doing your pregnancy management and attending your birth appeals, that’s tending towards private birthing and thus private health insurance. But it has high out of pocket costs on top of the insurance premiums. (Note also that private health insurance policies are expensive if you include obstetric coverage, and will always have a 12 month waiting period for it, so you must obtain it before pregnancy.)

I was reasonably happy as a doctor’s clinic patient for my first birth. If I was low-risk I’d probably likewise go public, ideally with a birth centre or caseload midwife pregnancy+birth.