Choosing your model of care and individual care provider is one of the most important decisions of your VBAC journey. And with growing awareness of all the different ways this model of care could look, it is becoming an increasingly complex decision.
No longer is the choice - Public hospital or private hospital. But we have private midwives, homebirth, freebirth, and doulas and student midwives added in to the mix.
As always - which model of care will be best for you comes down to, well, you. What you want from this journey and how you want to feel during pregnancy and birth will largely dictate which option is best for you. And options are limited in many areas, especially in rural locations.
In this blog post I'm going to go through 3 of the most popular models of care and rate them against my top 3 considerations: Client autonomy; Chances of a VBAC; and What happens in an emergency.
Private obstetrician in a private hospital
If you have private health insurance, you will likely be steered towards this option. It can a great option if you have decided that you want a planned caesarean or a planned induction. Of course, different care providers will rate differently against my criteria (and you may have your own criteria!), but overall this option rates pretty low.
Cost for a private obstetrician varies - most women tell me that they were out of pocket between $5k - $10k.
Client autonomy - 1/10. The only reason this rates a 1 rather than 0 is because there are certainly some OBs out there who will value their client's autonomy. Generally speaking though, an OB can drop you from their care if they don't like your decisions. I've seen women dropped from care for declining continuous monitoring, choosing a VBA2C, and declining VEs. If you value autonomy and legally valid consent processes - Private OB is probably not for you.
Chances of a VBAC - 2/10. Again, this will vary from provider to provider. But this model of care brings with it the lowest chances of having a VBAC. Make sure that you ask your care provider how many VBACs they have attended over the last month.
What happens in an emergency - Many private hospitals aren't set up for extreme emergencies and you will be transferred to your nearest public hospital. For example if your baby is extremely premature or you have severe placenta accreta you will need to give birth in a hospital with the appropriate level of care needed for this situation. Also, many private hospitals don't have staff on site 24 hours a day. So, if you have an emergency during the night there can be a small delay in getting staff in. Again - you will need to ask them what their emergency procedures are. Genuine emergencies are quite rare, and in the private system many women are given a caesarean during standard business hours if things are even hinting at not going exactly as the OB would want.
Standard care through a public hospital
This is the most common model of care for women in Australia. I'm including here Midwifery Group Program, hospital clinic care (OB and midwifery), and GP shared care. The reason for putting all of these together is that they are all "governed" by the hospital policies. I know that there will be some contention around lumping MGP in with "standard" care however I don't have the space in this blog post to separate them out and they rate very similarly in my criteria.
This is generally free - although some tests and procedures may have costs associated with them. A student midwife is free. A doula will vary, but you can expect to pay between $1k - $2k depending on the package that you get.
Client autonomy - from a legal perspective 10/10. In practice though.... I've seen some really dodgy "consent" processes, lots of manipulation, and a very unnecessary amount of bullying and coercion. If you know your rights and are confident in advocating for yourself you'll be able to sway this rating in your favour.
Chances of a VBAC - about a 3/10. Although that increases to 6-7/10 if you want a VBAC and go into spontaneous labour (ie - if you don't end up with a planned caesarean). You can also increase your chances of a VBAC by declining many of the non-evidence based procedures, staying home as long as possible, and hiring a doula.
What happens in an emergency - Depends on your local hospital. Most public hospitals (especially in metropolitan areas) have 24 hour emergency care. You can be receiving emergency care within minutes. But, as always, you will need to ask your care provider as this is sometimes not the case. If you have a very premature baby or other serious complications you or your baby (or both of you) may need to be transferred to another hospital.
Private midwifery is taking off in leaps and bounds at the moment! More and more women are wanting the continuity of care and the option to stay out of the hospital. Private midwives can usually support you at home or hospital (you do need to ask them as some only attend at one or the other) and are generally focussed on birth as a normal family event.
Costs will vary from around $3k - $8k. Some midwives are able to offer medicare rebates for some services.
Client autonomy - This one is extremely tricky to rate due to the politics surrounding private midwifery care and vexatious reporting at the moment. I've seen midwives who are 10/10 and some who would barely rate a 2/10. It is really important to have a very thorough and open conversation with your midwife about the politics in your area, their relationship with the hospital, and any restrictions that they are under.
Chance of a VBAC - 8 - 9/10. Women who hire a private midwife with a view to having a VBAC at home have a 90% chance of actually having that VBAC. If they are hiring the midwife for support in hospital that goes down slightly, but is still what I would consider to be very good.
What happens in an emergency - If you are homebirthing and the midwife sees that emergency care is needed she will call an ambulance and you will transfer to hospital. One of the benefits of having a private midwife with you at home is that most complications are caught before they become emergencies. The majority of transfers to hospital are for non-emergent care.
Many women believe that the more money you spend, the higher the level of care. But this just honestly isn't the case. Knowing what you want from this journey, knowing your care provider and their philosophy, knowing your rights, and knowing what makes birth safe are going to get you way further than spending $10k.
I totally understand than in individual communities the considerations may not be so clear and also that you may have other things that you would consider important when making your decision around what model of care you would like.
If you would like some individual support to assess your options and work out what might be best for you, please get in touch. I'm offering introductory sessions for $99. These sessions can bring a deep clarity and help you get this VBAC journey off to a fabulous start!
Much love, Lizzie.
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