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Childbirth Education: Knowledge is Power with Emma Sutherland, Kerry Sutcliffe and Dr. Kate Levett

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Childbirth Education: Knowledge is Power with Emma Sutherland, Kerry Sutcliffe and Dr. Kate Levett

At 37 percent, the rate of Australian caesarean section procedures is already one of the highest globally, and is projected to hit 45 percent by the year 2030. Join fx medicine Ambassador Emma Sutherland and guests Dr. Kate Levitt and Kerry Sutcliffe for an evidence-based discussion on the current birthing landscape in Australia.  

Kerry first takes us into the fascinating history of childbirth to help us understand the drastic changes from women-led, community-based birthing to the modern medicalised and seemingly disempowered process of birthing. She discusses the main drivers leading to C-section, recognising the prevalence of trauma around birth and how clinicians can provide knowledge and tools for an overall positive birthing experience.  

Dr. Levett layers in results from her current research which provides insight into the importance of working with a woman’s support structures (birth partner, family, allied healthcare practitioners) and following their preferences that can ultimately lead to profound birth and health benefits. She provides important information on how birthing guidelines are developed and how giving frank, open and honest information driven by the woman’s birth experience requirements helps to support a more effective (in both cost and personal experience) labour. 

Covered in this episode

[00:48] Welcoming today’s guests: Kerry Sutcliffe and Dr. Kate Levett
[03:53] The current context of birth and how it has changed throughout history
[09:20] Common reasons people seek out childbirth education programs
[13:06] The development of childbirth education programs
[15:23] Differences between standard antenatal education programs and complementary therapies ones 
[18:08] The role of the birth partner
[21:48] How to support our clients to have a better birth journey for more optimal outcomes
[26:00] Lowering the rate of unnecessary interventions
[27:59] Discussing the findings of Dr. Levett's PhD in complementary therapies for labour and birth
[33:26] The goals of birth education
[36:00] Providing tool kits and emphasising positive mindset
[37:19] Discussing Dr. Levett’s next prospective meta-analysis on c-sections and what the outcomes might be
[43:05] Getting evidence into pregnancy guidelines
[46:42] Cost savings from using complementary therapies during birth and how this can impact healthcare costs nationwide
[52:12] Changing the statistics on birth
[54:47] The future of birth in Australia
[56:39] Thanking Kerry and Dr. Levett and final remarks

Key takeaways

  • The prevalence of C-section interventions during birth is on the rise in Australia. The top three drivers include:  
    • The fear of pain during birth, including the pain of uterine contractions.  
    • Convenience to schedule the birth for both the patient and the obstetrician. 
    • C-section can be perceived as being less traumatic for the baby. 
  • Historically birthing, and women, were revered and women of a tribe supported the birthing process, and the tribe would support raising the child. Childbirth education was experienced more openly throughout communities. 
  • The increased medicalisation, routine interventions and systematic process of hospital birthing in Australia can be attributed to changes in birthing practices, societal perception of birthing practices, and training of male physicians throughout the centuries. 
  • 1 in 3 women experience birth trauma. Childbirth education aims to provide women and families with the information, tools and experience for a positive birth underpinned by understanding that each will be unique so the education must cater to this. 
  • There are many options available for childbirth education without set standards. It’s imperative to question what’s important for a woman’s experience and match the education to those requirements. 
  • A large Australian study shows that the people involved in supporting a pregnancy into birth and the environment where a birth occurs has a six-fold impact in an uncomplicated pregnancy experience. 
  • Providing women and birthing partners with knowledge of the birthing process (such as functional pain) and providing options that increase empowerment, awareness and understanding of complementary therapies has proven to reduce intervention and support positive experiences during and post birth. 
  • Most guidelines aren’t based on the evidence base to set their recommendations increasing the need for robust studies to guide future recommendations for implementation nationwide.  

Resources discussed and further reading

Dr. Kate Levett

Dr. Kate Levett
Dr. Levett's website
Research: Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour (BMJ Open, 2016)
Research: Cost analysis of the CTLB Study, a multi-therapy antenatal education programme to reduce routine interventions in labour (BMJ Open, 2018)
List of Dr. Levett's research


Emma: Hi, and welcome to fx Medicine, where we bring you the latest in evidence-based, integrative, functional, and complementary medicine. 

fx Medicine acknowledges the traditional owners of country throughout Australia. We pay our respects to elders, past and present. 

Today, we are lucky enough to have two experts joining us. First is Kerry Sutcliffe, who has a background in psychology and counselling. Kerry is also a childbirth educator and a PhD candidate at the School of Medicine, Sydney, studying the impact of childbirth education on birthing outcomes.

We also have with us today, Dr. Kate Levett, who is a senior research fellow at the University of Notre Dame School of Medicine, and also an adjunct fellow at NICM Health Research Institute in Western Sydney University, and an honorary fellow at the Centre for Midwifery, Child and Family Health at UTS. 

Kate is also an experienced acupuncturist and focuses her clinical work and research on the use of complementary medicines for maternal and reproductive health outcomes. Her PhD investigated a complementary medicine antenatal education program for pain relief in labour, and I cannot wait to dive into the insights from this study.

Today, we're going to be discussing the landscape of birth and looking at how current research is shaping the future of birth in Australia. Welcome to FX Medicine, ladies. Thank you so much for being on the line with us today.

Kerry: Hi, Emma. Thanks for having us.

Kate: Hi, Emma. Thanks for having us.

Emma: In Australia, there are approximately 300,000 babies born each and every year. In 2020, our caesarean section rates were, on average, 37%, with a breakdown of 29% for women birthing in a public hospital, and 43% for those birthing in a private hospital. Our national C-section rate is currently one of the highest in the world. The current global average of C-section births is 21%, and the World Health Organization has projected Australia's C-section rate to hit 45% by 2030. 

Now, reasons for this increase vary, but three main drivers have been identified. The first is the fear of pain during birth, including the pain of uterine contractions. The second is the convenience to schedule the birth when it is most suitable for families or healthcare professionals. And lastly, C-section can be perceived as being less traumatic for the baby.

Today, I want to deep dive into the world of birth and bring into light the extensive experience of both our guests so that we can learn how we as clinicians can help women be more informed and prepared for birth. 

Now, Kerry, can you give us some highlights around the historical landscape for birth? Let's set the scene with this.

Kerry: Yeah, that's a really good first question, actually, Emma, because often, we don't stop to think about the current context of birth, and yet our approach to it is a result of how we got here. So looking at the history of birth gives us a really good insight into why we do what we do now. 

So, a lot of what I'll mention now comes from Dr. Rachel Reed's book called Reclaiming Childbirth as a Rite of Passage, which is a great resource if anybody wants to go away and know more. But in a very quick nutshell, I'll kind of take you on a whistle-stop tour of birth. So, if we go way back, and I'm talking several thousands years ago, female figures and the birth process was very highly regarded, and while the women were the ones giving birth to babies, the collective tribe helped to raise them. And so we had many female gods, and women in birth and pregnancy were revered.

But the development of agriculture over time changed how people were living, and instead of a matricentric society that centres on the mother, patriarchal societies ruled by men and involving ownership of land emerged. And alongside this, religions where we'd previously seen separate female and male gods now became kind of one overarching father God. So now nature was deemed as being below humans because we were owning the land and humans were inferior to the Father God. 

So, women's reproduction, which was tied to nature, so thinking, for example, how menstruation was following the cycles of the moon, women were now deemed as less important, and religions were claiming that women should be subordinate to men. However, childbirth was one area where women maintained knowledge and power. And women and wise women who attended births were providing holistic care for the women in their care.
So, lots of our current birth practices, though, originate from Europe, and in the 12th century, universities appeared that were offering higher education to wealthy men. And so, male physicians, which were supported by religious and state leaders, then began positioning themselves as the only legitimate medical practitioners, and that ultimately started to see midwives trying to be pushed out and eradicated. But within their communities, they were still really highly regarded, although women knew the value of their expertise and knowledge. So, in a further attempt to kind of push them aside, they were described as witches, and over the centuries, whilst they lost control of medicine overall, they still retained childbirth.

And then, in the 16th century, science started to shift that power because human bodies were then thought about in mechanistic terms, and the invention of medical instruments to offer solutions to complicated births such as forceps, which only male physicians were allowed to use, and then saw the emergence of the man midwife, or the male midwife, which was the predecessor of obstetricians. 

Emma: Okay.

Kerry: However, they were only called upon in kind of complicated births. So again, there was a bit of an exaggeration of the dangers surrounding birth, but then wealthy women who could afford their services would bring them in for a just-in-case kind of scenario.

Then going to kind of the 1700, 1800s, the Industrial Revolution, it led to overcrowded towns and cities. So, there was more general sickness and injuries. And so, childbirth fever rates, which were increasing at the time because doctors were spreading bacteria from sick, or even death people to birth. So, death due to high infections was high until antibiotics were discovered, and birth was seen as this increasingly dangerous event. 
So by now, birthing in the hospital was fairly common, although home birth was still the norm for much of the kind of up until the second half of the 20th century. But in the earlier part of the 20th century, we had twilight sleep, which involved women taking highly sedated drugs, going into a sleep state, waking up after having a baby but with no recollection of it, and were having to be strapped down to beds to avoid injuring themselves because they were kind of moving and thrashing about due to the drugs.

So, we had a kind of situation where in the mid-1900s, male partners were in waiting rooms unable to be with their partner. Women were increasingly saying, "We want to be awake for the births of our babies." And then this led to the start of the structured childbirth education courses that we see today to give women and partners some strategies to cope in labour. But even since we've had this increased medicalisation, routine interventions, often we see birth as this event now that has to be quite efficient and timely. The 1980s were quite a technocratic approach to birth, and also the fear of litigation came about. 

And so we kind of find ourselves, now in Australia, with the majority of women giving birth in the hospital, is kind of around about the 93% of women who give birth in hospitals. We have high intervention rates. There's a lot of fear surrounding it. And this is kind of how we've got to where we are today. So it is important to look at that history to see how our approach over all those generations and years has led us to now being a position where this is how women commonly approach birth and give birth in a hospital setting.

Emma: Yeah, it's so big, isn't it? And I love that explanation. It really helps me understand why we are where we are with birth in Australia at the moment. And things have really changed, sometimes in a better way, and sometimes not. 

But as a childbirth educator, you're speaking to women that have birthed all the time, what themes reoccur in their birth experiences? Because I know, for me, whenever I am speaking to a new patient that's a woman, and she is a mother, part of her case-taking is asking about birth and pregnancy and her birth experience, and it just amazes me the amount of times that tears automatically come to a woman's eyes about her birth experience. And it might've been 20, 30 years ago, but birth experiences have such a profound impact on a woman.

Kerry: Oh, they do. It's such a transformational time in a woman's life to be giving birth, and this is something that will stay with her for many years and decades to come. In terms of the kind of the themes why as a childbirth educator, women would initially come to me in terms of why they're wanting to seek out courses is that, firstly, we've got first-time parents who never done this before. They don't know much about birth, and like I described in that history of birth, were not around it in the same way now. It's moved into hospitals. We're not attending births as once upon a time, we might have been supporting family members and stuff as well, too.
And there's a lot of scary stories surrounding birth. I find it very interesting how people share this information for women in the lead up to their own births, whether that's well-meaning, family members and friends, or the person who's behind us at the checkout at Woolworths, but it's really interesting how women are set up for birth. 

So, our perception of it is influenced for many years and even decades before we ourselves are the one who's pregnant from TV, and movies, and so on. So when we are pregnant, this can often be our real first experience of it, the first time we've really given any consideration to what we want to do and how we want to manage it. And we have become kind of detached from that process.

For couples who might come to child education who've already had a birth, it's very much that they're tending to be looking for a different experience, and maybe their first birth unfolded in a way that they didn't expect or they weren't feeling prepared for, and they're seeking to have a more empowering birth. 

So, as a childbirth educator, it's my role to help provide women and the support person with knowledge and tools for all eventualities. So, I really want women and families to come out of the birth feeling good, feeling positive about their experience. And a positive experience can look and feel like different things to different people, and that's okay. It's not about creating births, or look and feel the same, because it's not possible. Every birth is different, every birth is unique, and a really personalised and individualised approach is what should be central to this.

What I find is that when women and partners are given tools and techniques to help them navigate the birth, that they start to understand labour and how their bodies work, or given information and knowledge to educate themselves about the pros and cons of different approaches, they often can utilise that to come out of birth feeling good, even if sometimes the birth may take on a different path. 

But you're right, those tears flowing that you mentioned, birth trauma is very real. They talk about how about one in three women experience birth trauma. A lot of that is put down to what's said to the woman or how it's said to her. And then about 1 in 10 go on to develop post-traumatic stress disorder. So there's a real range of experiences that women come out of birth experiencing, and, unfortunately, we hear lots of negative stories. But it is possible to have a positive experience when you've got the right support, the right care providers, the right circumstances, the right knowledge, information, and tools. I think it's important that we also let women know that this can be a very positive, empowering experience.

Emma: Yeah, 100%. And those childbirth education programs, who develops them in the first place? They have such an important role, education is key in this space, but who actually develops them? And how do women access them? Because there's all different types of programs out there.

Kerry: There is, and kind of in terms of who actually develops them is quite interesting, really, but there's no standard approach to what goes into classes. It could be very much up to the people within the hospital in terms of what they cover. Hospital is where women largely access information regarding pregnancy and birth, and this is partly because some of the evidence around childbirth education can be conflicting. So, some studies show some improvements in some areas, some studies show improvements in others, other studies might not show any improvements. So with so many mediating factors present, it's also a little difficult sometimes to know what worked in one situation but not in another, perhaps. So, there an organisation called CAPEA, which is the Child and Parenting Educators of Australia, which does a great job. But there's no requirement for people to register with that.

So, the content of courses and how they developed can be influenced by what has been in the course to date at that place, the interests of the people who are coordinating the courses, time available to develop them, and the ethos and the philosophical approaches of the place that's delivering them. So, I think this has led to some hospital courses being outdated. Typically, they can't or don't move as quickly, perhaps, as the independent sector. So, I'm seeing a growing number of courses from outside providers, which, from my own experience, are becoming increasingly popular. Women are seeking information from alternative places.

So, you're right, it can be quite confusing for women to know what to do in preparation for birth, whether to do it with the hospital, an external provider, in a group, one-to-one. And so, I suppose my advice around this would be to choose a course that has content that's most likely to help you to prepare for the birth that you do want. And so I think there's some thinking that women need to do there in terms of what is this birth all about for me, and what does it look like? What would be a positive experience for me? And who's going to help me gain the tools and the knowledge to achieve that as much as possible?

Emma: So, if we sort of zoom back a little bit, if you had to put it simply, what would be the main differences between a standard antenatal education program and one provided by, for example, the complementary therapies of labour and birth program that Kate has studied? How can we talk to our patients, the women in front of us, about the differences between these two options they have?

Kerry: So, the standard kind of hospital-type courses, there is a bit of an argument that they're set up to promote compliance with hospital policies, that they can be focused more on the medical management of birth, rather than what a woman can do to help herself and support herself during labour. So, women talk about how when they've come out those courses, sometimes they're quite largely focused on the drugs that are available, or how an epidural works, but in terms of how the woman can cope with her own resources and her own capacity to give birth, it isn't as well addressed in some of those classes.

I do think there's a bit of a shift happening in some hospitals. I think that's largely prompted by the increasing popularity of external providers. So, thinking of the complementary therapies for labour and birth program that Kate and I work on, this course has more of an emphasis on non-pharmacological ways to support a physiological labour. So, physiological, a woman using her own coping strategies, working with her own body, labour and birth. And what I find with this course is that it's providing techniques to help a woman either feel more in control or stay calmer, help to reduce the pain associated with birth, thinking of it as a functional pain, it's her body doing something to birth her baby, and importantly, bringing in partner support as well, because I think they're often an untapped resource in the birth room, and yet that birth partner is probably the person who knows mum's best, and if we can enhance the support that they're able to offer, this could be beneficial to women.

So, the course itself includes a number of techniques, things like breathing, acupressure, visualisation, upright active positioning, that partner support, and so on, talking about the amazing hormones that a woman has within her that's supporting labour. And I think that's a real major part of the course as well, that once women and partners start to understand what's happening within a woman's body to support this, I think they then don't necessarily automatically start seeking out the medical interventions. They think, "I've got this toolkit of other things that I could be doing to support labour and birth."

So, in a previous study, and I know Kate's going to go on to talk about this, so I won't talk too much, but we saw a significant reduction in kind of the use of epidurals, and caesarean rates, and so on. So, women and partners were finding this very useful to support physiological birth.

Emma: Yeah. And I think the role of the birth partner, I know you've done a lot of work in that space, but from my experience clinically, you mentioned it's an untapped resource, and I think this is so true because to have that birth partner also empowered and be in that space with purpose can make the difference between whether that woman ends up having a physiological labour or whether it becomes a medically-managed birth.

Kerry: A hundred percent. I completely agree with that, and that's where my interest lies as well, in terms of my PhD in the work that I'm doing on that.

Emma: Yeah, tell us more about that. I'm interested.

Kerry: Yeah. So I'm interested in how childbirth education gets translated into practice. So, I think it's one thing for a woman and a partner to attend a course and be given information and techniques about what can help in labour, but it's another thing to actually be able to apply it during the labour itself. So, for me, the interesting part of what's going on is about what's happening between the woman and the people around her. So her partner, any other support people, the midwife, doctors, and so on. And what is it about those relational aspects that might create barriers or enablers to child birth education techniques being used?

So, my study and my research has got an emphasis on researching that partner support, the role of the care provider, and how a woman's own kind of reactiveness when she's feeling anxious impacts on what she does. So why might a woman who was previously using childbirth education to good effect then decide to stop using it at some point in labour? So, I'm using a theory, it's called Bowen Family Systems Theory, and it's a theory of human behaviour that views family members or people we spend a significant amount of time as, as like an emotional unit. So, it uses systems thinking to describe the complex actions and interactions that take place between a member of a family. It talks about how we live under the same emotional skin, so we're so intensely connected to these people that they profoundly affect each other's thoughts, feelings, actions, and we might even be able to think of this in our own relationships that we have, a spouse, or a child, or a colleague does something, and it has an impact then on maybe what we do, or say, or how we do something next.

So, this theory has a big emphasis on anxiety and how people differ in their ways of coping in stressful situations where there's heightened emotions. And I can't think of many other events in life as emotionally charged as birth. So, it's really well placed to look at why a woman might continue or discontinue what she's learnt in class during her labour. And I'm kind of really excited to see what might come out of this because I think that relationship factor could be a really important mediating factor in the use of, and the usefulness of childbirth education.

Emma: Yeah, and working out that missing link between if a woman has the knowledge and awareness, but then something happens that she can't apply it or continue applying it, what is that missing link? Because if that was addressed, obviously, that would have a huge ripple effect across the outcomes of birth nationally.

Kerry: Yeah, absolutely. Definitely. It is that missing link. Why is it that some women can be so armed with knowledge, information, and techniques, but then, for some reason, it just doesn't get used in labour and birth, or it gets given up, and so on? What is happening at that point? And I really do think that the people around the woman at that pivotal point in labour can be making a real difference as to whether or not she continues to use these techniques or potentially then starts to look at different options.

Emma: Yes, absolutely. And I've read in your PhD proposal that our current maternity system tends to direct more than listen to women, and that antenatal education is often biased towards the medical management of birth. 

Now, we're talking to a whole heap of clinicians, including myself. So I really want to know, how can we better support our patients in their birth journey so that they have more optimal outcomes?

Kerry: Yeah, I think it's really important as clinicians to let women know that knowledge is power. It really is important to educate themselves to be aware of how we as workers impact them. If we can build more agency in women, then, hopefully, that will help them to kind of drive change in the system if they feel that they can be empowered, that they can use this kind of information, that they can seek more, I suppose, in terms of their birth experience. There's a vast array of different approaches to birth, and I believe there's something like 11 different models of care here in Australia. So, it's a confusing system for women to navigate.

Now, depending on whether you're at a hospital, or at home, or which care provider you speak to, women can be given very different recommendations and support. So, encouraging them to feel confident to ask questions, to weigh up the pros and cons of different options available to them, because the different models of care have varying outcomes. There was a study done that looked at 1.2 million births here in Australia, and when they looked at uncomplicated pregnancies, which was a single baby, reached full term, they were head down, in comparison to giving birth in a hospital labour ward, the odds of a normal labour and birth were twice as high if they were at a birth centre, six times as high if they were at home.

Emma: Wow.

Kerry: So, where and whom you birth with has a big impact on the birth you may go on to have. So, making them aware of that kind of information, and as clinicians as well, working in a collaborative manner, using your specialisms to really support the woman in the lead up to birth, and whether that's kind of encouraging her to seek out childbirth education or also have a session with an acupuncturist, or an naturopath, or gain the support of a doula. I think it's really important that women feel that she has people around her who are supportive, who she feels safe with in the lead up to enduring birth, and who are aligned with helping her to achieve a positive and empowering experience. We all have our own biases. I think it's really important for us to acknowledge that as well and then put that aside and be supportive of the woman and her decisions.

Emma: Yeah. And I think birth itself is so primitive. As a woman who's given birth myself, you enter this sort of primal state, and it makes sense that the people around make a big difference to your experience. As you started out, we used to birth with wise women and surrounded by women that really had our back, so to speak. So, I think that the awareness is really important, it is a transformational time in a woman's life, and knowledge is power. I can't agree with you more on that front. And just keep on seeking out more knowledge. But those birth stories that you get when you're in the line at the supermarket when you're heavily pregnant, oh, my goodness.

Kerry: Yeah. It's an interesting one, isn't it, to think that, how are we setting women up for birth? Women are not going in particularly confident if they're always hearing the horror stories, and the negatives, and stuff like that. And interestingly, I find as well that women who do have positive birth experiences sometimes feel a little shy about sharing them for fear of feeling like they're bragging. And it's not that they're bragging, they're... No, I had three very positive birth experiences, and here's nothing special about me. I decided that I was going to take some ownership for this birth, and I was going to find some information, and I was going to develop techniques. And I knew medicine was there as a backup, should it be required, but I armed myself with some other things first to say, “Let's use these, strip it back, let's get back to basics, and let's do this.”

Emma: Well, it is a very natural event, and the normalisation of birth is something that we do have to keep focused on.

Kerry: Yeah, definitely.

Emma: Now, Kerry, one last question before I let you go. How do you think we as clinicians can help to lower the rate of unnecessary interventions? What can we do?

Kerry: I think, first, it's worth noting the importance of that question about being unnecessary interventions, because there is a time and place for intervention, and I'm sure that for many people who might be listening to this, we have access to good obstetric midwifery care if it's required. But it's also really important to know that for women, there is high intervention rates, and we need to question why that might be. So, the World Health Organization talks about how labour and caesarean rates, genuine medical need in around 10% to 15% of pregnancies. However, in Australia, first-time mums is about a 46% induction rate. You've already mentioned the caesarean rate was at 37%.

So, I think for clinicians, for many of them, they may be seeing pregnant women more than the birth professionals, the health professionals. If a woman's having a weekly appointment with an acupuncturist, a naturopath, or going to yoga sessions every week, the information and the support that they're providing can really help to build confidence, making them aware of their options, encourage them to educate themselves. Stick with our own areas of specialism, but also have that collaborative approach.

So, as clinicians, make links with other pregnancy and birth professionals in the area so that we can all work together to enhance pregnancy, birth and the postpartum. And really, it kind of comes back to the fundamentals of relationship-based care, evidence-based recommendations, and also recognising that risk doesn't inherently lie within a woman's body, which is what a lot of women can sometimes think, but the interventions themselves, whilst they can be lifesaving at times, the overuse or the inappropriate use of them can cause problems, too. So, really just encouraging women to gain information, educate themselves, and support them in their lead up to birth with the specialisms that you have and to really promote that for her.

Emma: Great. Some very wise words there, Kerry. Thank you so much. 

Now, Kate, your research has fundamentally helped shape best practice evidence in this field of birth. Can you share with us a little background on your PhD paper, which was complementary therapies for labour and birth study. Tell us what you discovered in that PhD?

Kate: For sure. Thank you. We didn't know what we would find going in, and so it was a really great kind of outcome, I think, for everyone because so far, before we started the study, there was very little evidence about the impact of antenatal education or childbirth education. And so it was sort of much of a muchness. There was no the latest systematic review kind of said. There's no real evidence for change in obstetric outcomes, that sort of thing, and so nobody was really focusing very much on area. And when I did my PhD, when we implemented this program, and it was at two hospitals in Sydney, one was a large tertiary hospital and one was a smaller sort of district hospital. So, we got a sort of diverse range of women and backgrounds, but the type of woman we found who was interested in participating in the study was largely similar. So, we need to take it in with a little bit of a context of the women who are likely to participate versus the women who are not likely to participate, which is where it leads to Kerry's PhD, which I think is an interesting sort of point there. 

But we found that at the end of the study, there was a significant difference in the use of epidural use, which was what our primary outcome was. Because it was a small study, we used an outcome that was sort of more common, and so that was epidural use, and we found that there was a big difference in epidural use between the two groups, the study group and the control group who received standard hospital care. And the study group received standard hospital care, plus this two-day workshop where we introduced five complementary therapy techniques to support labour and birth, as well as information about normal physiology of birth, as well as directed supportive care techniques for the partners. And the partner could be anybody, and it could be more than one person. So it was whoever the woman chose to bring with her.

So, that sort of three-pronged approach was how the whole course was interactive, and we found a significant difference then in rates of epidural use. Women were much more likely to use complementary therapies, and on average, they used between three and four different therapies during their labour, which is an...

Emma: Wow.

Kate: ...important point. It's not just a one-size-fits-all. They used different things, and there was no one thing in particular that contributed to this lowering of epidural use, although acupressure was probably the most likely. 
Then we also saw, on the back of that, a reduction in augmentation rates. So there was less need for augmentation once an epidural wasn't used, and then we saw the outcome of interest was that caesarean section was lowered, and that's where the real difference lies. There was also a difference in the time for second stage of labour, there was a difference in rates of perineal trauma, and also a requirement for resuscitation of the newborn. 
So, there were some pretty major outcomes that we found from the study, although it was a small group, and although the women who participated tended to be higher educated, higher income, and from a sort of more socio-demographically advantaged area of Sydney. So, that was our particular demographic.

And we saw in the qualitative outcomes that partners said that their favourite or their best-used technique was acupressure. So, that was something that they felt drew them into the birth space.

Emma: Oh, great.

Kate: They were able to use acupressure and some massage technique, that was the second-most used one. Used those sort of manual therapies to help their partner to get through whatever aspect of labour it was that they were working on. And they also said that once they understood the normal physiology of labour and birth and what they were aiming for, so that educational background about normal physiology, then they were much more likely to implement those complementary therapy tools. But it was based on an understanding of normal physiology. Otherwise, they just kind of go, "Well, why acupressure? Why massage? Why hypnosis? What's the point of it?" And when they understood the point, then they were able to use it with sort of some intent. So, that was really, I think, an interesting finding.

And then we found, from midwives, saying, they said, "Well, look, we're too busy to do the education in our antenatal visits. We can't skill them up on these things. Women who come into labour with education are easier to work with." And they also said that they follow the woman. So, if the woman comes in and she wants sort of lots of technology and interventions and that she needs that support, then they'll do that. So, that's the technological approach. If she wants lots of supportive caregiving approaches, then they'll work with that. So, they follow the woman with her approach, is the other thing they said. So, that, I thought was interesting, too. They don't really have much impact, they felt, once a woman is already in labour.

Emma: Yeah. And fascinating, fascinating outcomes. And I can see why that was a little surprise to see so much change with a two-day educational course that sounds like it was very kind of hands-on as well. 

But with that birth course that you studied, what were the main objectives of the birth course? What do people walk away with?

Kate: The main objectives were around education. So, education around normal birth, but also accommodating for variations in that. So, we're not trying to say, “Look, you have to have this or you have to have that,” because every woman's circumstances are different, and she needs to work with whatever her story is. And so, you just don't what's happened to women or where they're coming from or what their particular circumstance is. But coming from a basis of, okay, this is normal physiology. This is what we can work with, and now, let's overlay that with what your particular circumstances are, which we don't always need to know, but she will need to know, and then what can we work with? So, the thing I'm interested in is induction of labour. Like Kerry said, we've got, I think, an over 40% induction of labour right at the moment. 

Another study that Kerry and I have been involved with, one of the outcomes about the first baby study, was that women don't really understand the impact of induction of labour.

Emma: I would agree entirely because I hear it clinically all the time. It's something that happens to them, and they don't seem to be involved in that decision-making either.

Kate: One hundred percent. And they said if they had a question for after birth, if they'd been able to ask anything more that they didn't understand in the first place, what would it be? And the majority of them said about induction of labour. So, they would want to understand the implications of having an induction, because it's passed off in the clinical setting of, "Oh, look, we'll just induce you on Tuesday. It's no big deal," and it is a big deal, and women are traumatised by it. And there's lots of incidences of women walking away from birth feeling like they've had a traumatic event. And so, I'm interested in then, okay, so this is happening in my clinical setting, where you've got an induction scheduled for a particular reason, you want to go ahead with that. Now, here's some techniques that will support you and your partner to manage that induction.

Emma: Great.

Kate: So, it's not about removing interventions because some women really need it, it's about managing what happens after that. If your pain tolerance is altered, or you've got a background of trauma or something's happened that you need an epidural, you go ahead, but here's how to manage that. Or you need an induction, here's how to manage that. So, that's what I like to focus on, about how to use these tools and techniques to manage normal and also to manage deviations from normal.

Emma: So, it sounds like there's a lot of education that's passed across in this course. There's a bit of a toolkit of complementary therapies for pain relief, which is super handy, and then it's a lot of positive mindset regarding their capacity to give birth.

Kate: Yes. The positive mindset is really key, isn't it? And that a woman has an understanding about what it is that she wants, is involved in decision making, and has some agency in her birth despite what else is happening around her, that she and her partner have decided that this is what they would like to aim for, and everything that happens, they have decision-making capacity. They're informed, they have agency in there, and they are the ones who are making the decisions at the end of the day. And they have a right to make a decision in any way they want based on full and frank information. So, that, I think, is important that for clinicians, it's an everyday event for them, but it's a one-off for women.

Emma: Yes.

Kate: So, that real disclosure about pros and cons of every intervention, or every management that's going to occur, and that women, at the end, they have the ultimate decision-making capacity.

Emma: Yeah, which in turn lets them walk away from that experience feeling empowered and not disempowered. 

You’re currently working on a prospective meta-analysis, which is going to assess whether the addition of a comprehensive multi-component birth preparation program reduces C-section in women compared with the standard hospital care. 

So, first of all, what is a prospective meta-analysis? If you can just talk us through the technical side of it there. And then how will this answer the question about antenatal education and C-sections, and why is it important to address our high rate of C-sections? We know it exists, but I guess, why is it important to address it? And what do you think you're going to find from this study?

Kate: Good questions about the prospective meta-analysis. And I think it's something that is relatively novel in this area, but if we think about a standard systematic review in meta-analysis, if anyone's ever read one, it's putting together a whole lot of research studies that have addressed a similar question. So, maybe we've got antenatal education programs and someone decides to do a systematic review in meta-analysis, they put together these different programs, so they've kind of done different things, they've assessed different outcomes, they've got different cohorts of women, they've got different lengths of time and outcomes that they're looking at. So, we're putting these studies together, and then we're trying to do an analysis of outcomes, and you come to the realisation that nobody's collected the same data, and you can't put it together. And so, it's like, well, the studies were too different and we weren't able to really put it together to see what the overall outcomes are, so we don't really know the answers still. 

What a prospective meta-analysis does is there are teams of researchers who have decided that they are going to, say, run a program of antenatal educational childbirth education, and we agree beforehand on the outcome measures that we're going to collect. And so we've got a range of outcome measures, we've developed the data dictionary, we've developed primary outcomes and secondary outcomes that are of importance, and we've involved clinicians, stakeholders, consumers, and different representatives from different states, territories, and countries who have come to a consensus about what the important outcomes are, and how it is that we might collect it.

So we might have different programs. You might have a yoga program that you're doing for childbirth education and you've used some mindfulness and hypnosis in there, I've got an acupressure program that I'm using, and I've got some yoga and hypnosis, and somebody else has got a different program, and they've got three different techniques as well. So, we've decided we're going to put those together, and the basis is that we've got three different complementary therapies involved in our program. We've got some education about normal physiology and how to manage other comprehensive physiology in there, and we've also got a mindset component. So, those three components, we've agreed, are in our courses, and we've also agreed that we're going to collect particular outcomes.

So on the basis of that, we can put our studies together, even though they're different and diverse and have different women, we can put our studies together because we've captured the same data. So, that's what a prospective matter analysis does. And in that way, we can have a much more robust investigation of these research studies to say, “Well, look, there's a whole lot of different programs out there, and when we look at overall rates of epidural, caesarean section, and maybe induction of labour, we can see that it has an impact in this way and for these types of women.” We're able to do a secondary analysis about what types of women it might be most effective for, and collect much larger sample size. So, our overall sample size is 2000 women...

Emma: Okay, great.

Kate: ...as opposed to a smaller study where we'd get maybe between 200 and 400 women.

Emma: I'm already excited. I don't know when the results are going to be released, but what do you think you're going to see? I think the hypothesis is that there will be a reduction, but what are your thoughts?

Kate: That's what we're looking at. So, is there going to be...? On the basis of having 2000 women involved in this kind of study, we will be able to detect a difference of 5% in caesarean section rates. So, the bigger the sample size, the more capacity you have to detect differences in those outcomes that may be a little bit less common. So, caesarean section, even though it's at 30% to 35%, it's still considered less common than maybe other outcomes. And you need about 2000 women to be able to see if there's a difference of about 5%, which people think is clinically significant. So, if we've got a reduction from 35% to 30%, that would be a clinically significant outcome that we're interested in.

Emma: Okay. That makes sense.

Kate: And if anyone has a program... And it's an ongoing study. So, at the moment, we've got two studies that are involved in the program in putting this data together. But if there was another study, so say a group from New Zealand wanted to do a program of childbirth education, they could say, "Oh, listen, Kate, we're wanting to do a study as well. What are the outcomes you're collecting? We'll make sure we incorporate those outcomes into our study, and we'll work with you in putting the data together at the end of the day." So, anyone out there who, really, has any interest in doing a study about childbirth education, this is something that you can join as a collaboration to be able to test on a bigger hypothesis what your outcomes might be.

Emma: Great. So this is going to be quite dynamic, and the information will continue to unfold, which is fantastic. 

Look, the use of complementary medicine in women who are pregnant, it is high, and recommendations have been included in some of our maternity guidelines in Australia. And, Kate, you are a co-author on a paper this year. Looking into this, what did you learn? What was highlighted here?

Kate: Yeah, this was really fascinating to me, that we've got all these complementary therapies, we've got good evidence for complementary therapies individually, we have good evidence for women liking complementary therapies. We've got good evidence for usage in pregnancy, it's up around 60% to 80%, depending on the demographic that you're looking at. It's really high usage. And so, we thought, "Okay, on that basis, we'll have a look at the guidelines." We know that it takes a long time for evidence to get into guidelines and into practice, on average, 17 years.

Emma: Oh, gosh.

Kate: Yeah, that's a really long time. And when we looked at the guidelines, we looked at every state and territory across Australia, and we found that in all of those guidelines, there was some pretty good information about vitamins and mineral intake. So, iron supplements, or vitamin D, or things like that, they were the things that people addressed most comprehensively.

We had about 48 guidelines, and there were 41% of them that went more than the routine vitamin and mineral supplementation. So, a smaller proportion. So in those guidelines, there was such wide variations in what the recommendations were that there was not really that much consensus. There was things like consensus on ginger and vitamin B6 for nausea and vomiting, there was some consensus around supplementation for women with obesity, but the guidelines, overall, scored quite poorly around the domains, looking at editorial independence and rigour of development. And what does that mean?

The rigour of development is about how did they do their search strategies, what evidence did they look for? And we found that most guidelines do not rely on the evidence base to make their recommendations. And that's really interesting. There was no evidence of a systematic review for them, of a search strategy, or that there was editorial independence, in that there was a group of people from diverse backgrounds, including stakeholders and consumers, who had input into that guideline. And so that's where I think state guidelines, state and territory guidelines can really make a big improvement.

Emma: Absolutely. I'm a little shocked. As a layperson, even as a clinician, I would presume that those guidelines were based on the evidence.

Kate: And the one that was the best was the national guidelines, so the Perinatal Society of Australia & New Zealand, PSANZ. There's a national guideline, and they were probably the most comprehensive and had the best search strategy for evidence. But it still wasn't that comprehensive. And then all of the other guidelines sort of based their guidelines on that. But even within some guidelines, there was two in one particular state, within their own guideline, contradicted themselves.

Emma: Oh.

Kate: So, there's real work to be done. And guidelines are really great way to get evidence into practice, and it's a pretty simple way. It's not that arduous to be able to incorporate those things, and it's a way to inform clinicians about the latest evidence. So, that's where I feel like there's a gap, and that we can fill that gap. That's some work to be done. So, that's where we're focusing a bit of our attention at the moment.

Emma: Fantastic. Now, you also wrote a paper on the cost analysis on the complementary therapies for labour and birth program and how this program can impact the healthcare costs of birth. I would love to hear more about the detail of this.

Kate: Right, yes. We did do a cost analysis based on that original PhD study, and the cost analysis was interesting. And I worked with this brilliant health economist, Federico Girosi, that was a great experience, about how you investigate cost analysis. And we used the basis of, okay, so who are we deciding is paying for this? Women are paying for it, and the health system are paying for it.

And looking at that basis, we used the health cost data within hospitals. So, say you've got a woman, and she comes in, she has an induction of labour, and then she gets an epidural, and then she has a normal vaginal birth. Then you've got a woman who comes in, she has no intervention, she's in spontaneous labour, she has a normal vaginal birth. Those two women are costed in exactly the same way despite their resource usage. So, they're costed as a normal vaginal birth. So, it's a little bit of a blunt tool.

But, so we've got those women, they're costed under normal vaginal birth, and then we have women who are like, okay, they came in, they had this and that intervention, they ended up with a forceps or a vacuum birth. Those women are costed under an instrumental vaginal birth. Then we have another group of women who are costed under caesarean section. But if you have a woman, she comes in, she has an induction of labour, has an epidural, ends up having a forceps birth, that's failed, and she has to go in and have an emergency caesarean section, we costed her in the caesarean section group. So, it was the highest level of intervention. So even though she was costed across three domains, she only lands in the one where the highest level of intervention was. So, it's a mutually exclusive cost analysis. Does that make sense?

Emma: Yeah, completely. Yes.

Kate: All right. Okay, so even though you've got lots of different levels of usage and cost within those groups, that's the way the health system works. So, you've got a cost analysis based on that data. What we found was that the group where caesarean section was involved, that's where the most cost saving was for our study group versus our control group. And a caesarean section cost twice as much as a normal vaginal birth. So, an uncomplicated caesarean section was the largest group, and those women, on average, we'd say we spent about $149, $150 per woman on delivering the intervention. So, that's the childbirth education program. So, that's where we added costs. So, $150 for a woman doing it. And then we've also got cost of service, so midwives who might be delivering programs, or care, or etc., etc. But we found that we saved about $808 per woman involved in the study group, and that was mainly based on a reduction in caesarean section.

So, with a cost of about $150 on average, and a reduction of about $800 on average, the cost is about $650 per woman. And when you average that out over first-time women birthing in Australia, that's about 120,000 women per year, the cost saving translates to $97 million a year.

Emma: Wow, it's unfathomable. That's quite incredible. And this is a program that is empowering women, and women are very satisfied with, saving $97 billion for the Australian economy, that's incredible. This needs to be happening in every hospital, doesn't it?

Kate: It does. But you can see there's a lot of layers around this. So how do you demonstrate the cost, and to whom? How do you influence guideline development? How do you get a bigger study so that you can talk about which women will benefit most, and it's replicable? How do you look at this in rural, regional, remote? Is it best online? And that's where Kerry's study is really looking at, is online delivery going to be as good as in-person delivery? Which we were kind of forced into having a look at that through COVID. 

So, where do we focus our efforts so that we can get the maximum gain? And is it just financial gain that we're looking at? Women's access in rural and remote Australia might really be where we're gaining later on through reduction in mental health care costs down the track, where we could really put it out there, where are we saving money and health services in a long-term picture?

Emma: Yeah. Look, I think the research in this space is going to be continually evolving, but there are so many different layers to it. But just starting with those basic fundamentals of a good antenatal program that helps women have a better experience, feel more empowered, and to have less intervention overall is such a fantastic thing. 

Kate, you are actually also a practising acupuncturist. You're a very busy lady. Can you share with us any clinical pearls that will help us as clinicians change the statistics on birth?

Kate: Yes, and I'm really honoured, I suppose that's the word, to have this clinical practice where I see lots of pregnant women, and I love working in that space. It really just gives me so much joy that we've got such opportunities to help women and their partners and clinicians. So, I work a lot with the hospitals that are nearby to me, and I've got good relationships with the MGP midwives and some other clinicians there, I've got good relationships with the doulas in my area, and I will invite any of those clinicians to come into treatments with women so that we can have a continuity of care.

And I find that I've probably got the most contact with women in that space if I'm seeing them maybe for fertility, and then they get pregnant, just to see the whole pregnancy journey and then we're prepared for birth and all that stuff. I've seen them a lot where their clinicians may have seen them less, especially if they're in fragmented care models. So, it's a really great opportunity to be able to educate women just little by little as they go along, "Let's talk about this week, and let's educate or refer on." I often refer to Kerry's childbirth education where she does other childbirth education programs, plus the acupressure. We've got a good collegiate network, so that's great.

When women come in from about 36, 37 weeks of pregnancy, we start to prepare for labour and birth. And so that's around mental, physical, emotional preparation. We're looking at cervical ripening and readiness for birth, and also that intermediary between what they're telling them at the hospital and how we can manage them in that space. So, I need to have an epidural, or I need to have a this, or I can't have that, or whatever it is. Okay, now let's work with that with your partner. So I invite the partner to come in and teach the partner about massage techniques, acupressure techniques, pain relief for labour, how to be emotionally supportive, how to be physically there, what role they can have, and the importance of their role. I'll invite the doula in, if the midwives want to come, whoever wants to come, invite them into that space to be able to do that overall education so that I can pass that on and give the woman the most empowerment possible and continuity into the hospital's system.

Emma: Yeah. Amazing. I think there's just so many layers involved. 

Kerry, I'd like to bring you in. I just want to know, what do you see as the future of birth in Australia?

Kerry: Yeah, a big question.

Emma: It is.

Kerry: Where are we going? I think the last couple of years with COVID has really shine a light on the importance of women feeling emotionally supported leading up to, during, and after birth. Women want both clinically and psychologically safe births. We've already spoken about the birth trauma and the PTSD rates. But when a baby's born, so, too is a mum and a family. So I think the narrative around “all that matters is a healthy baby” really needs challenging, and if a mum or a dad is kind of broken from that birth, we need to think about the wider implications of that. And research keeps telling us the importance of continuity of care with an own midwife. It has so many benefits for women and babies. A Cochran review that looked at 11 trials, 12,000 women that were lower medium risk, when they looked at that, women were less likely to be hospitalised antenatally, less likely to lose a baby before 24 weeks of gestation, more likely to have a spontaneous vaginal birth, more likely to feel in control, less regional algesia, less episiotomies, less instrumental deliveries, and babies were staying in hospitals for shorter period of times, and there was no increased adverse outcomes for women's or babies in midwifery-led care.

So, I'm hopeful that practice will catch up with the evidence. Kate's mentioned, on average, it's around 17 years, but I really hope that more money will be invested into midwifery group practice models or access to home birth for women who want to access this, and I think importantly, as well, women's voices are going to become more and more powerful. Pregnant women are savvy consumers, and they're, I think, as well, a top-down approach to changing birth that is looking at the evidence into guidelines and policies and so on, alongside a bottom-up approach that's led by women demanding more from their birth experience will be a key driver in what shapes the future of birth in Australia.

Emma: Yeah. Amazing. Well, thank you so much for joining us today, ladies, and sharing your wisdom and experience. Birth is a transformational time, and knowledge is power. 

Thank you, everyone, for listening today. Don't forget that you can find all the show notes, transcripts, and other resources from today's episode on the fx Medicine website, fxmedicine.com.au. I'm Emma Sutherland. Thanks for joining us. We'll see you next time.


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