The experience of expecting
A story of antenatal experiences in Australia and beyond
By Susan Burgess
February 2024
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Content warning: This article discusses pregnancy loss, fetal death and maternal fatality. Please be advised that this may be triggering to some people.
None of my children were born in Australia. In fact, for about two months after they were each born, they were, in effect, citizens of no land. Such are the peculiar beginnings for many expat children – born abroad and waiting for a piece of paper declaring them to be citizens of a land they have not yet visited. This is my roundabout way of admitting that I have not, in fact, given birth in Australia. I have seen it portrayed on television and I’ve experienced it anecdotally, but I have not lived it.
Despite my naïveté in this area, however, there is one thing I do know without a doubt – Australia continues to be one of the safest places on earth to have a baby (Ritchie, 2020, August 31).
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Sarah’s story
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Sarah* gave birth to her second baby in the May of 2021. Early in her pregnancy, she enrolled in a midwifery program through her local hospital. She relished the idea of a program designed to “support women who want a natural, intervention free birth, want to breastfeed their babies and are happy for early discharge if all is well after the birth”.
Her prenatal care included not one, but six home visits from her midwife as well as an almost overwhelming amount of information. She was well prepared for pregnancy, well prepared for birth and well prepared for the postnatal period. She reflects on her experience: “I think that…I was given the confidence to be able to be calm through my labour and delivery”. She laboured in a hospital, but with very little intervention from the midwives. “It was a wonderful experience,” she asserts, “and I felt very empowered”.
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Rebecca’s story
Rebecca* also gave birth in 2021, in a tumultuous year marked by prolonged lockdowns and frequently changing health policies due to COVID-19. She had experienced the heartbreak of miscarriage and a devastating stillbirth several years earlier, which meant a more closely monitored pregnancy and a scheduled Caesarian section. She explains, “due to my history, …hospital staff were keeping a closer eye on me and the baby throughout the pregnancy”. Like Sarah, she describes her wonderful post-natal care in the hospital, where “a lovely group of midwives…advocated for [her]”.
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The grim worldwide reality
Everyone’s experience of pregnancy and childbirth is different, but in stark contrast to both Sarah and Rebecca’s stories, Hannah Ritchie points to the 830 women who “die from pregnancy-related causes on any given day” (Ritchie, 2020, August 31). She believes that a “world where very few women die from pregnancy is possible”, but in the face of such harrowing statistics, it feels a long way off.
In a perfect world, she argues, we would just “make all countries rich”, as wealthy nations generally have better outcomes for mums. But, as we can all appreciate, this solution is neither quick nor easy, so she instead focuses on “effective interventions beyond economic growth”, which can inform policy change and translate to significant improvement for countries with struggling or slow-growing economies.
She identifies two key factors that have made a significant impact on maternal outcomes in poorer nations: antenatal care and births attended by qualified healthcare personnel.
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Antenatal care
According to UNICEF, “antenatal care is essential for protecting the health of women and their unborn children” (2024, January). It is an important form of “preventative healthcare” where women are supported physically and emotionally through pregnancy and given necessary medications, immunisations and treatments. When we look at worldwide data on antenatal care, through much of the world is invested in providing expecting mums with at least four antenatal visits during pregnancy, we see that disparities still exist (UNICEF, 2022).
Births attended by qualified healthcare personnel
The prevalence of dark green in the map below tells us that it is now the norm worldwide for women to be supported through childbirth by skilled healthcare personnel, whether that be a midwife, a nurse or a doctor. Like Sarah and Rebecca, 96% of women in Australia are attended when they give birth (AIHW, 2023b). Similarly high figures are replicated across much of the world. However, this is not the case everywhere. In Somalia, for example, only 31.9% of births are assisted and, in 2020, 621 women died per 100,000 live births, making it one of the most dangerous places on earth to have a baby (WHO, n.d.).
Where to from here?
According to Ritchie, consideration of comparative data, especially by countries experiencing high rates of maternal deaths, can help increase “political pressure on the government” to respond as they consider “the progress of neighbouring countries” (2020, August 31). In this case, therefore, knowledge is power; an understanding of the current state of play is vital in pushing for change.
But what about us? While we might be tempted to smugly pat ourselves on the backs here in Australia and look down our sunburnt noses at the rest of the world, I would urge against complacency. Our mates ‘across the ditch’, our geographical and cultural neighbour New Zealand, saw an increase in the maternal mortality ratio between 1990 and 2020, from 6.65 to 13.6 per 100,000 live births. The United States has experienced an even more dramatic upward trend from 8.2 to 23.8 (Ritchie, 2020, August 31). Though, on a world scale, these numbers are not catastrophic, they are surprising trends, and one can’t help but think that there, but for the grace of God (and robust perinatal healthcare policies) go we.
Closing the gap
Finally, we must consider and confront the very real inequities that still exist in our own country. Much rhetoric has surrounded the notion of ‘closing the gap’ for at least the past decade and a half. The government has been producing Closing the Gap reports since 2009 (Australian Government, n.d.-a) and a formal partnership was established between federal and state governments and the Coalition of Aboriginal and Torres Strait Islander Peak Organisations in 2019 to “accelerate improvements in life outcomes for Aboriginal and Torres Strait Islander people” (Australian Government, n.d.-b).
The data, however, reinforces what we perhaps already know. It tells the story of a nation that’s still a way off when it comes to closing the gap in terms of outcomes for mothers and babies.
So where do gaps currently exist?
Heartbreakingly, the rate of fetal death amongst babies of First Nations mums is still nearly twice that of the non-Indigenous population and First Nations mums are almost three times as likely to die during pregnancy or childbirth. Babies to First Nations mums are still more likely to be born early and have a lower birthweight than non-Indigenous babies (AIHW, 2023a & 2023b). The following charts highlight these discrepancies.
And there remains a gap in prenatal care. A minimum of five antenatal visits has become the standard of care in Australia, but there is still a disparity between First Nations and non-Indigenous women in this regard. While 95.5% of non-Indigenous mothers had five or more antenatal visits in 2021, this figure drops to 87.6% for First Nations mothers (AIHW, 2023b).
What can we conclude?
The issues are overwhelming, but they are too important to overlook. Good policy must address this gap and continue to uphold a high standard of care for all women.
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Sometimes this takes an innovative approach. In Brisbane, Professor Yvette Roe has seen great success through the pioneering Birthing in Our Community service (Australian Government, 2023, May 22). The service reimagines maternity healthcare provision. According to Roe, "the community-controlled services created a community hub to provide services outside the hospital. Feedback from the women about the hub was it 'feels like home' and 'feels like a black space'. This safety net for women was critical to the outcomes." This pilot study is currently being translated to rural and remote settings, where the gap for mothers and babies is even more pronounced.
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It is exciting innovations like this, developments that embrace collaborative partnership and First Nations values and practices, that seem to hold real promise when it comes to improving outcomes for mums and their bubs in this nation.
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*pseudonyms have been used to protect anonymity
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References:
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Australian Government. (n.d.-a). History of closing the gap. Closing the gap. https://www.closingthegap.gov.au/resources/history
Australian Government. (n.d.-b). Partnership. Closing the gap. https://www.closingthegap.gov.au/partnership
Australian Government. (2020). Child mortality. Closing the gap report 2020. https://ctgreport.niaa.gov.au/child-mortality
Australian Institute of Health and Welfare. (2023a). Data tables: National maternal mortality data collection annual update 2021. Mothers and babies: Data. https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/data Licence: CC BY 4.0
Australian Institute of Health and Welfare. (2023b). Data tables: National perinatal data collection annual update 2021. Mothers and babies: Data. https://www.aihw.gov.au/reports-data/population-groups/mothers-babies/data Licence: CC BY 4.0
Ritchie, H. (2020, August 31). Exemplars in global health: Which countries are most successful in preventing maternal deaths? Our world in data. https://ourworldindata.org/exemplars-maternal-mortality
UNICEF. (2022). Maternal and newborn health coverage. https://data.unicef.org/resources/dataset/maternal-newborn-health/ Licence: CC BY-NC-SA 3.0 IGO
UNICEF. (2024, January). Antenatal care. https://data.unicef.org/topic/maternal-health/antenatal-care/
World Health Organisation. (n.d.-a). Maternal and newborn data. Maternal, newborn, child and adolescent health and ageing: Data portal. https://platform.who.int/data/maternal-newborn-child-adolescent-ageing/maternal-and-newborn-data Licence: CC BY-NC-SA 3.0 IGO
World Health Organisation. (2023, May). Preterm birth. https://www.who.int/news-room/fact-sheets/detail/preterm-birth#:~:text=Preterm%20is%20defined%20as%20babies,(32%20to%2037%20weeks)