Mother-of-four Catherine Nillson has a lot of personal experience with Canberra's public maternity system.
"I've had a water birth, a theatre birth, a land birth and a chaotic birth," she said.
When an obstetrician told Ms Nillson to have a caesarean section for her fourth, when she wanted a vaginal birth, she felt confident to make her own choice.
"Women from a low socioeconomic background or from a non-English speaking background, they're not going to argue," Ms Nillson said.
Two-in-five births
At 38 per cent of first births and 42.1 per cent of all births, the ACT has a higher rate of caesarean sections than any other state or territory, new data from the Australian Institute of Health and Welfare shows.
The first birth rate has increased by 25 per cent since 2019.
Australia-wide, 38 per cent of all births in 2021 were caesarean sections.
The ACT rate "is pretty appalling", midwife and Australian National University academic Dr Kai Hodgkin said.
"Given that we are considered a very healthy, well-educated community, we shouldn't have a caesarean rate anywhere near as high as it is," she said.
The high rate of c-sections could be due to many things, but staffing levels in the ACT are a "big issue" and caesarean births make it easier to manage workloads, Dr Hodgkin said.
"[It is] reflective of a wider systemic issue of over-intervention, fear of risk, a culture of hierarchy, low staffing, people in a rush, risk-averse policies," she said.
She did not think parental preference was behind increasing rates.
ACT Health data shows that, except for teenage parents, the older a mother is, the more likely she is to have a c-section.
First-birth caesareans increased by more than 50 per cent from 2011 to 2021, while the average age of mothers at birth rose by 1.1 years.
There may be more births in the private system compared to other jurisdictions, Dr Hodgkin said.
In 2014-16, ACT private system had twice as many caesareans as the public hospitals, according to ACT Health data.
Are c-sections really that bad?
Caesareans "are absolutely necessary and life-saving and essential" for some, and no one should feel ashamed for having one, Dr Hodgkin said.
"[But] from a systemic level ... we are actually having more than we need."
Risks include blood loss, clots and transfusions, issues breastfeeding and complications at future births, Griffith University researcher and retired specialist obstetrician and gynaecologist Dr Kirsten Small said.
Babies are more likely to have breathing issues, jaundice or struggle regulating their body temperature, she said.
They are also more likely to have a metabolic disorder, like obesity or diabetes, by five years old, a Western Sydney University study from 2017 found.
In 2021, the World Health Organisation (WHO) said "caesarean section rates higher than 10 per cent were not associated with reductions in rates of maternal and newborn mortality".
The risks of having a c-section or vaginal birth for each individual need to be weighed up carefully, Dr Small said.
"Caesarean sections introduce women to a group of risks that they weren't going to be exposed to if vaginal birth is what happened for them instead," she said.
"If you're going to make a recommendation for a caesarean, you want the potential benefits to supersede those potential risks [and] over time, we've gotten better at reducing [the risks of having a c-section]."
Feeling pressured
Parents can feel pressured into having medical interventions without knowing the risks, Maternity Choices Australia ACT branch president Catherine Bell said.
"The interventions themselves are not the problem when they're needed," she said.
"The trouble [is] we hear a lot of reports of women saying they didn't really understand what they were consenting to.
"If you have a medical professional in front of you making a recommendation saying, it's probably very hard to disagree with that."
Ms Nillson said she felt pressured to have a caesarean birth for her second child, who was in breech, but the obstetrician did not fully explain the options.
"The obstetrician [said], 'well, your baby will die'. And I said, 'but what's the likelihood of that actually happening?' [He said] 'oh no, it will happen'," she said.
There is a higher survival rate for babies in breech born via c-section.
Guidelines for obstetricians state vaginal breech births "may be a safe option for carefully selected women".
'Gold standard'
Having had four children in the ACT's public health system, Ms Nillson is happy overall with her experience.
"Canberra has a wonderful public maternity system, and there's no reason to pay all the money to go private," she said.
Her first three births were through the Canberra Hospital's midwife continuity of care model.
Parents are assigned a midwife who stays with them throughout pregnancy and birth.
Ms Nillson's student midwife for her first, Evelina, was the same for her second, Annika. They are still in touch.
The midwife continuity model is the gold standard, Dr Small said.
A 2016 study by Professor Caroline Homer found it reduced the chance of stillbirth by between 16 to 25 per cent, and babies were less likely to be born pre-term.
There was no reduction in induced labour or caesarean sections.
There were 341 people on the waitlist for the Canberra Hospital's two programs on July 24, Canberra Health Services said.
North Canberra Hospital's low-risk program has about 18 to 20 people waiting per month.
The ACT government has committed to at least 50 per cent of pregnant people having access to the model by 2028, and 75 per cent by 2032.
We've made it a whole lot easier for you to have your say. Our new comment platform requires only one log-in to access articles and to join the discussion on The Canberra Times website. Find out how to register so you can enjoy civil, friendly and engaging discussions. See our moderation policy here.
