AMA (NSW) Birth Trauma Inquiry – Opening Statement

The Australian Medical Association (NSW) would like to thank the select committee for the opportunity to provide a submission to this inquiry and for the chance to appear before you today. I would like to acknowledge the traditional owners of the land on which we meet.

My name is Dr Kathryn Austin, i am the vice president of the AMA (NSW) branch as well as a practicing obstetrician and maternal fetal medicine specialist. I work in both the private system and the public hospital system where i practice general obstetrics and the highest risk obstetrics through maternal fetal medicine. I have undertaken additional subspecialist training to also hold this maternal fetal medicine qualification allowing me to work with the highest risk and most complex pregnancies for families from across NSW. I work with an extraordinary group of talented doctors, midwives, nurses and allied health workers, all of whom share the same passion and commitment for maternity services. 

The AMA acknowledges the experience of birth trauma felt by large numbers of women over many decades. 

Those of us working in health believe that it is crucial that the system we work in should be seen, felt and fundamentally be safe because it is through that prism of safety, that trauma can be minimized. 

We believe it is important to recognise a safe system needs to involve physical safety and psychological safety.

It should be acknowledged that Australia has among the world’s lowest rates of infant/maternal mortality. This is thanks largely to a strong health system but also due to the multiple forms of intervention available to medical and midwifery professionals to address a multitude of birth impacts. These figures are obviously welcome but we need to ensure that our strong physical outcomes are matched by similar outcomes in psychological safety.

We acknowledge the NSW health blue print for action in maternity care. The blue print has a sound evidence base, has been well informed by feedback from mothers and families and those working in the health system. Unlike the previous NSW health policy, towards normal birth, the updated blue print document seeks to provide options for women rather than creating expectations of one particular maternity pathway being “normal”. We believe there is no such thing as a “normal” birth. 

While many births in this state and across the nation occur without complication every birth, every day has the potential for risk. We believe that a lack of understanding of the scope of risk and frequency of birth impacts has contributed to the levels of trauma experienced.

We note that many of the submissions of those with lived experience express how a lack of information and understanding exacerbated their feelings of trauma.

What is often not well understood, is the prevalence of the many – possible – physical – and – emotional impacts of birth. 

The Australian institute of health and welfare reports that in 2019 of all the women in Australia who gave birth vaginally 85% suffered some degree of perineal tear. 

Around 1 in 5 women or 20% will require some form of instrumental intervention in their delivery. This statistic is largely unchanged over time.  As i remind my patients, we generally will not know which will be the one in five. Contrary to social & mainstream media suggestions, and well meaning non-medical advice, it is nature, not the patient, which will determine who will require assistance.

Pre-term delivery occurs in approximately 7-8% of pregnancies. Pre eclampsia affects 3-10% of pregnancies. Gestational diabetes is now diagnosed in up to 15% of pregnancies. Rates of all of these known pregnancy risks are significantly higher in multiple pregnancies. Increasing maternal age and elevated body mass index will also add complexity to pregnancy. These are simply some of the figures that demonstrate pregnancy carries innate degrees of risk often unbeknownst to people prior to conception that can in many cases endanger their life or the life of their baby. 

In many, maybe most aspects of our lives we are used to having some and usually a large degree of control. What cannot be prepared for is when things suddenly and unexpectedly go dramatically off plan. We believe that women are not given enough preparation for the significant, overwhelming and often terrifying loss of control that can occur. This can happen to any woman at any time. 

Birth by nature can be painful and unpredictable but that does not mean it will result in trauma. We believe the best ways to reduce trauma are by:

• Building the confidence of women and their families by providing better antenatal and postnatal education, 
• Informing women of the spectrum of procedures associated with birth, 
• Involving women in decision making as much as is possible and 
• Discussing birth outcomes in the postnatal period.  

Essentially better education at every stage of the birth journey for a better informed birthing experience.

These discussions should involve medical and midwifery input so that women understand and are made aware that whatever their hopes or plans, they may require medical intervention. The possibility of requiring medical intervention, should be seen as part of the normal birthing process, not an unexpected or traumatic outcome.

ManY of the submissions to this inquiry refer to the frustration felt by expectant parents at a lack of continuity of care in the public system. This is a frustration shared by doctors and other healthcare providers. Lack of continuity is an unfortunate consequence of workforce pressures. 

I refer you to the ockendon review of maternity services, conducted in the uk and released in 2022 which we will table. It calls for an appropriately funded model of care which allows birthing units to be properly staffed and to be funded in a way that all forms of care can be delivered in concert. It recognises that safe staffing levels must be addressed, including back fill to ensure staff are able to to both provide and attend training, as well as measures to address the record rates of attrition as maternity staff burn out and move on. 

The review calls on regular emergency drills, and better training at all levels for antenatal cardioteocography or ctg – the monitoring of a baby’s heart rate, as well as for the creation of better systems of training in compassionate care, particularly for families who have suffered bereavement.

The AMA believes the best outcomes are achieved by a collaborative, multidisciplinary team-based model of care, with each profession supporting and respecting the opinion and approach of others. When doctors, midwives and other allied health workers act in concert early recognition of risk factors that may cause pregnancy or birth complications are better identified, birth outcomes are improved and postnatal complications are reduced.

An example of exceptional collaboration is that of medical professionals and physiotherapists – a collaborative model of care which from the beginning of pregnancy could provide significant safeguards to prevent birth impacts including trauma. We believe physiotherapy services should be provided extensively both before and after birth.

We do however suggest measures be put in place to ensure that information provided by non-medical advisers does not contradict evidence-based care and we believe expectant parents should receive education in relation to the difference between medical and non-medical advice. 

For example being told that a so-called “natural birth” with no form of intervention is best for your baby and that all forms of intervention including pain relief, forceps, vacuum or emergency caserean must be avoided at all costs. A “natural birth” (air quotes) in which a baby is breach, has a cord around its neck, a shoulder stuck in the birth canal or ? Could lead to serious and lifelong implications or even death. More rare but serious conditions like a uterine rupture – in which the uterus breaks open and the baby’s heart rate drops to zero, if left to nature would almost certainly lead to the death of the mother and the baby.

Doctors want what expectant parents want. A birth that is medically and psychologically safe for both mother and child. 

The AMA believes there needs to be realistic pathways to adequate antenatal education. 

Just as important is postnatal education. Studies have shown repeatedly that when explanations are provided for what happened, why things did not go to plan and where necessary what intervention was required, the level of trauma felt is vastly reduced. 

Education for expectant parents is not the only answer. Among the solutions should be better training and resourcing for those providing services for them. 

We believe there should be greater screening for those who may be pre-disposed or at greater risk of birth trauma so that trauma-informed care can be tailored to address further needs.

There must also be robust mechanisms in place to identify psychological distress and clear pathways to access emotional support and specialist support where needed as soon as is possible. All of these require significant resourcing and workforce and simply adding these to already overburdened staff is not the answer.

Working in maternity services is an incredible privilege. We live through every mother’s story, every baby, every joy and every loss. We accept that tragic outcomes are a part of our job and feel that the experience of vicarious trauma among maternity health workers should also be acknowledged and addressed.

High quality maternity services rely on a stable medical, midwifery and allied health workforce. There is a concerning risk that the result of this inquiry could lead to a loss of workforce, thus inadvertently undermining the important objectives of increasing the medical and psychological safety afforded to patients. If the inquiry results in recommendations that are not safe for those working within the system, this could lead to a catastrophic failure to attract and retain the workforce we so desperately need, across this state. 

It is our hope to work with this inquiry to create a safe maternity service, both medically and psychologically, for all patients, and those working in the system.  

I am happy to take questions.