Last updated 16/01/2024
Choosing a care provider and location for birth is a critical early decision that can have a significant impact on the kind of care you receive during your pregnancy, labour, birth and postpartum as well as what kind of birth and postpartum you experience.
I didn’t have a complete understanding of my different care options when I fell pregnant with my first child, and I wish I had done much more research before becoming pregnant so that I would have been in a better position to make choices that aligned more directly with my values in pregnancy and birth.
That’s one of the first things you need to figure out before deciding on what kind of care you will be looking for and where you want to birth - what visions and goals do you have for your pregnancy, birth, and postpartum? Different care providers have different training and approaches to maternal health care and will therefore provide quite different services. Generally speaking, you will be choosing between midwifery care and obstetric care. Under midwifery care, there are a number of locations you could then choose to give birth, while obstetric care will usually always involve birthing at a private hospital (occasionally public hospitals).
Here's an excellent diagram created by Dr. Melanie Jackson (@melaniethemidwife) which demonstrates the relationship between care provider and birth philosophy that can help you understand what kind of care you will get from different providers. The explanation she posted along with this image is worth reading, which you can find here or an entire podcast episode on The Medicalisation Spectrum on the podcast she co-hosts called The Great Birth Rebellion.
Now, a breakdown of the different maternity care options in Western Sydney.
This is the most common option for maternal health care, and many women may not even realise that there are any other options for care during their pregnancy. In this model of care, you are seen by (usually) a different midwife at each appointment and most testing and scans are done in house. When you are in labour, you attend the hospital birth unit and are cared for by whichever midwives are on shift that day. You may also see obstetricians throughout your pregnancy, labour, birth, and postnatal period depending on your individual circumstances.
If you have an uncomplicated vaginal delivery, you can often be discharged as early as few hours after birth, but usually within 24 hours. Depending on how long you will be staying, you may leave straight from the birth unit, or you may be admitted to the postnatal ward. A longer stay would be expected for a delivery with complications or interventions like postpartum haemorrhages, episiotomies, or caesarean deliveries.
Public hospitals have varying degrees of staffing after hours, depending on what level of hospital they are and their areas of specialty. This will often factor into what treatment and attitudes you experience, particularly if you begin your pregnancy as deemed ‘high risk’, or if you develop a condition throughout pregnancy to deem you such. Smaller hospitals may refer you to a tertiary hospital (specialised staff, equipment and usually 24-hour operating theatres i.e. not on call staff for out of hours emergencies) further from home in these situations. These hospitals also often have a neonatal intensive care unit (NICU), which means if you gave birth there and your baby was unwell and needed to be admitted, you wouldn’t have to be in separate hospitals.
Being treated at a public hospital maternity unit means you are truly without continuity of care and may greatly benefit from hiring a doula on your journey to provide you with a level of emotional continuity of care. Continuity of care is time and time again shown to improve pregnancy, labour, birth, and postnatal outcomes for women and babies.
In my service area (Western Sydney, Hawkesbury, Blue Mountains, Macarthur), the public hospitals that you can receive pregnancy care at are:
Nepean Hospital (Tertiary, NICU)
Hawkesbury District Health Service
Blue Mountains District ANZAC Memorial Hospital
Westmead Hospital (Tertiary, NICU)
Liverpool Hospital (Tertiary, NICU)
Midwifery Caseload/Midwifery Group Practice
Midwifery Caseload or Midwifery Group Practice is an amazing option for continuity of care with a known midwife over the duration of your pregnancy, birth, and postpartum. In these programs, you will be allocated a midwife (Caseload) or group of midwives (MGP) who will do all your antenatal appointments and be somewhat on call for your birth. Usually, there are a few midwives who rotate being on call, even for Caseload, so it will depend on who is rostered when you go into labour. Some Caseload and MGP midwives conduct some appointments at your home, while others require you to visit the hospital for them.
Westmead public hospital has a Caseload program, and Nepean, Blacktown, and Campbelltown hospitals have a Midwifery Group Practices (MGP). These programs are in high demand and book out extremely fast, which is another reason for investigating your birth options before falling pregnant - if you know what kind of care you want and that it is in high demand, you can call as soon as you know you are pregnant to book in.
Westmead hospital has a relatively large pool of Caseload midwives compared and also offer publicly funded homebirth as an option under the Caseload. They also offer a separate Caseload clinic called Dragonfly which is specifically for women and families identifying as Aboriginal and/or Torres Strait Islander, aimed at ensuring continuity of care for First Nations women.
Nepean, Blacktown, and Campbelltown Hospitals’ MGPs are another great option for women who meet a set of criteria, including living in the local areas. They are more likely to accept women on the lower end of the risk profile, however. They are also in quite high demand and so is worth getting onto very quickly after falling pregnant to ensure a place. In these programs, you will probably have a primary midwife out of the group, but you are likely to be rotated through depending on who is rostered.
Continuity of care with a known midwife is one of the best options available for women wanting to have an intervention-free or low intervention birth as research tells us that it reduces the risk of labour and birth interventions like assisted deliveries and episiotomies, use of pain relief like opiates or epidurals, caesarean sections, low APGAR scores for babies, admissions to special care or neonatal intensive care for newborns, and even the risk of perinatal mortality.
**Please note: Nepean are continuining to advertise "Caseload" services, but to my knowledge and understanding, this no longer refers to the Caseload program it once was with a single known midwife, but now refers to the the collective MGP and MAPS (see below) programs.
Other Local Public Hospital Programs and Clinics
Nepean Hospital – Acacia Clinic
The Nepean Hospital Acacia Clinic is a little-known gem available to low-risk women who are eager to have continuity of care but missed out on a place in the MGP program.
Acacia Clinic is run by third-year midwifery students who are overseen by a clinical midwifery educator. It is a brilliant option for continuity of care that not many are aware exists.
Other Local Public Hospital Programs and Clinics
Nepean Hospital - MAPS
MAPS stands for Maternal Antenatal and Postnatal Service and is a program being trialled at Nepean where women have continuity of midwifery carer for their antenatal and postnatal appointments. It is available to low-risk women in the local area.
It isn’t total continuity of care, as during labour and birth, women will attend the Birth Unit and be seen and cared for by whomever is on shift at that time, but you get some level of continuity with a known midwife throughout pregnancy and in postpartum. The midwives on the MAPS program are also able to attend to women at home for their antenatal and postnatal appointments.
You can read more about it here.
If MAPS was the closest you could get for continuity of care, you could bring on a student midwife or hire a doula to fill the continuity gap in labour and birth.
It's covered under Medicare like any other public hospital service.
Westmead Hospital – PAPOOSE
PAPOOSE stands for Pre And Postnatal cOllaborative Outpatients SErvice and is a clinic outside of the hospital where women having their first babies can receive their antenatal care and get to know their midwife.
As with the MAPS service, it isn’t total continuity of care, as women will attend the Birth Unit when in labour and be seen and cared for by whomever is on shift at that time, but your antenatal visits will be with the same midwife, and you may have a student midwife (if you would like and consent) follow your pregnancy with you who can also attend your birth, or hire a doula for the same.
It is another great option for first time mothers, as a lot of the antenatal care involves education around pregnancy, labour and birth and what to expect – something that there is often not enough time for during regular antenatal clinic appointments. PAPOOSE is covered under Medicare like any other public hospital service.
Other Local Public Hospital Programs and Clinics
Westmead Hospital - Breech Birth Clinic
This is such an amazing option for women with breech babies! Of course, this isn’t a clinic you would book into when you first fall pregnant, but it a really handy thing to know about in the case of a breech positioned baby.
Breech babies will often be born vaginally quite safely, it is usually just a variation of normal when it comes to delivery. However, in a lot of circumstances, women may find their care providers are either unwilling or unable to support a woman in a breech delivery. In the case of the unwilling, it’s usually due to a lack of confidence in breech birth procedures because it is so often referred for a caesarean these days, so many obstetricians and midwives have very little knowledge or confidence in delivery breech bubs.
At the Westmead Breech Clinic, the team is made up of an obstetrician, an obstetric registrar and a midwife who are experts in breech birth. They take women from about 36weeks onwards, when it is unlikely (though importantly, not impossible) that a breech baby will turn themselves. You can be referred by a GP, obstetrician, or midwife.
If you are interested in midwifery led care outside of a hospital environment, you may have already come across the term ‘birth centre’ and wondered if that could be an option for you. Unfortunately, in Greater Western Sydney, we don’t have any birth centres available to us. The good news, though, is that many of our hospitals in this area are undergoing or have recently undergone major renovations and expansions, and the birth units and labour wards have been or are being upgraded in that process to be much more relaxed spaces that feel less like hospitals and more like home. Blacktown Hospital recently underwent a full renovation and is nice and fresh, Nepean hospital has a beautiful new birth unit, as does Campbelltown hospital.
There are a few Sydney city based hospitals that have birth centres attached to them, RPAH and RHW for example, but you need to be in the area and part of the Midwifery Group Practice within those hospitals to access them for birth.
If you are wanting to birth at a private hospital, you would need to engage the services of a private obstetrician. Some obstetricians will also allow you to birth at a public hospital under their care, but generally, it will be at a private hospital.
A private obstetrician is not covered under Medicare as a bulk billed service. You will receive some rebate on your appointments, but there will be a significant out of pocket cost that is usually covered in part by private health insurance.
It is important to note that just because a woman has private health insurance that covers pregnancy, doesn’t mean that she should automatically choose to hire a private obstetrician. Place of birth and therefore choice of care provider has a significant impact on what kind of interventions and birth outcomes you are likely to have. For example, some of the private hospitals in our area have up to a 70% induction rate, others a 45% episiotomy rate.
If you are interested in a more medicalised approach to your care, or you know that you have existing risk factors that will make your pregnancy a higher risk case, an obstetrician may indeed be the best choice for you. However, if you are more interested in a hands-off, natural physiological approach to your pregnancy care, you may want to do some more research into the differences in midwifery-led and obstetrician-led care to decide which would be a better option for you.
If you decide to hire an obstetrician as your care provider, you then need to choose which obstetrician you want to hire. One of the best ways to do this is by interviewing a few to get a feel for whether they align with the kind of care you are looking for. Recommendations from friends, family and/or your GP may not always lead you to the right care provider, as it is a very subjective area and what one person considers to be good care may not be right for the next person.
The private hospitals in our area are:
Nepean Private Hospital
Westmead Private Hospital
Norwest Private Hospital
Southwest Sydney Private Hospital
You will need to contact obstetricians directly, rather than the hospital maternity wards, in order to book in with one.
Midwifery Group Practices/Caseload
As mentioned above, Westmead Hospital has introduced homebirth as an option for place of birth under their Caseload practice. It is important to note that while an absolutely brilliant option that is publicly funded, there are a number of strict criteria you must meet to be eligible. These include being low risk (and remaining that way throughout pregnancy), living within 30mins from the hospital and no history of caesarean sections, as well as others. There are also scans and tests that you must undergo to remain eligible. If at any time you become higher risk and therefore ineligible to birth at home, you would most likely still remain under the care of your caseload midwife but would need to present to hospital when in labour and birth there.
Privately Practicing (Independent) Midwife
If you are interested in birthing at home and are unable to secure a place in the Westmead Caseload program or simply wish for your care to remain separate from the hospital system, another option you have for a care provider is hiring a privately practicing midwife.
Privately Practicing Midwives (PPMs), or Independent Midwives (IMs) as they are sometimes known, work independent of the hospital system and will see you at home or at a privately run clinic for your antenatal and postnatal appointments, as well as your birth. A private midwife is more likely to accept you into their care for conditions that may exclude you from the caseload midwifery programs, but it is important to discuss with the individual midwife as to what she is comfortable with. Not being bound to hospital guidelines means private midwives are much more amenable to the women’s right to bodily autonomy and more respectful of their informed choices to either consent or decline various tests, scans or procedures throughout their pregnancies and births. However, if there are tests or scans that you would prefer to have, an independent midwife is perfectly able to give you the necessary referrals and order them.
Choosing a homebirth with a private midwife is an excellent and safe option for the overwhelming majority of women who are looking for a hands-off approach to their care and a physiological labour and birth. It’s also a great example of true continuity of care, as you will be seen by your hired midwife for all antenatal and postnatal appointments, as well as labour and birth. Your midwife is on call for you and would only ever not attend if she happened to already be at a birth - a very rare occurrence.
The cost of a private midwife is the only downside, as independent midwife attendance at labour and birth is not covered by Medicare. Generally, you will be looking at fees averaging $6-7k which (depending on the individual midwife) will usually cover all appointments (antenatal and postnatal), on-call and attendance at your birth, second midwife attendance at your birth, and often the provision of birth pool (should you want one). You will be able to apply for a Medicare rebate for the antenatal and postnatal portions of the fee once your midwife provides you with a Medicare receipt, usually after your care has wrapped with her.
If you are interested in a homebirth with a private midwife, it is recommended to speak to your local private midwives before even getting pregnant so you can find someone who you gel with. A good and trusting relationship is the most important factor when finding a private midwife, but they do tend to book out incredibly quickly, so doing this work before falling pregnant so you know who you want to hire and can contact them immediately (and I mean immediately, like as soon as those two lines are visible on that stick) is a very sensible approach. Don’t feel like you’re being too eager or over-preparing.
One other option that women may choose is birthing at home without clinical support.
Sometimes this is just the case of women who have had fast births and their midwife hasn’t made it in time, or they were planning on a hospital birth and weren’t able to make it in time, but in many other cases, women may have been seen at a hospital for their antenatal care but had every intention of birthing at home unassisted when the time came. However, there are also cases where women choose to birth at home without medical or clinical support where the woman has decided to forgo any antenatal care (often referred to as "wild pregnancy").
Women choose to birth at home unassisted for all kinds of reasons, whether because they have full faith in the body to grow and birth a baby and see no need for assistance, or because they want to avoid the hospital but have been unable to find a midwife to attend their birth, or in some cases that we have seen over the pandemic, it is women who have been in publicly funded homebirth models where the homebirth option has been suspended for a myriad of reasons due to the pandemic.
Some of these women will seek the services of an experienced birth doula, while others will just want themselves and their partner, or maybe a family member or friend. If interested in freebirth with a doula in attendance, be mindful that some doulas will not feel comfortable in supporting a freebirth and you may need to contact a few to find someone you click with.
Other members of birth team
A doula can support you as part of your birth team wherever and however you want to birth! They are in addition to your clinical care team - not clinically trained, but there to support you physically and emotionally through your labour and birth, as well as throughout your pregnancy and postpartum. A doula can help you plan and map your birth, prepare yourself for labour, understand you rights and options, attend antenatal appointments with you if you feel you want some extra support, help your partner feel empowered supporting you in labour, help keep you focused on your goals in labour, and so much more. If you want to understand more about whether hiring a doula is the right choice for you, feel free to get in touch with any questions.
References and links:
"Welcome to the Womb" podcast hosted by a Sydney midwife Em also has a great episode where she and a colleague discuss different models of care which can be a really useful crash course for the uninitiated - check it out! (the podcast is also available on apple podcasts if that is your preferred platform)