Perth Birth Nerd

The Homebirth Series, Reason #4

In this article, I take a critical look at hospital maternity care policies, using CTG monitoring as a major case study. 

Maternity care is one of the biggest systems in healthcare, serving around 300, 000 women in Australia each year.

97% of this care is delivered in hospital settings. The prevailing belief that fuels these numbers is that women who attend hospitals are having the very best care available. However, that’s not always true.

Many common policies, procedures and workplace norms in maternity care are actually conflict with the best scientific research we have about what gives the best outcomes for mothers and babies. Further to that, many policies are not written with the woman or baby’s long-term health outcomes in mind, and simply shift health issues downstream, to a later point in their journey. 

This was one of the main reasons I decided to birth outside the mainstream system, and with a care provider who had much more autonomy.

Policies are Necessary for Big Systems

Large systems, such as hospitals, which deal with large volumes of consumers, require streamlined policies and procedures. These policies need to account for:

• The minimum requirements for standard of care set out by their governing bodies
• Staffing- The types of expertise, and number of staff available 
• The constraints of the venue- the number of beds, the equipment available
• Occupational health and safety of the staff
• The measured Key Performance Indicators for that area of specialty (e.g. APGAR scores for newborns)
• Protecting the hospital and its employees from litigation by consumers and other stakeholders

With so much to consider, the written documents need to be concise, and don’t have much room for nuance. These policies are also difficult to change, as there is a lot of pressure on organisations to keep to the status quo, as there is fear of litigation should they step outside of that and something “goes wrong”. 

With this in mind, I am sympathetic to the staff and their managers, who have to work in a system that seeks to streamline a natural, biological process that varies so much from woman to woman. However, I am also quite unapologetically critical of some of these policies, in particular those that are culture-based (“we do it because we’ve always done it”) that are favoured instead of those that evidence-based, and lead to better outcomes.

Policies that are not Evidence Based

There are many policies or common practices that are common in maternity care in Western Australia that do not reflect the best evidence-based care. Some actually result in worse outcomes for mothers and babies. These include, but are not limited to:

• Routine vaginal exams during labour (Oladapo et al, 2017; Zhang et al, 2010; Down et al, 2013; Moncrief et al, 2022)
• CTG monitoring in almost every scenario (see below)
• Use of synthetic oxytocin for active management of placental birth (Fahy et al., 2010; Dixon et al., 2013)
• Coached pushing (Lee et al, 2019; Brancato, 2008; Lee et al, 2018)

These are routine interventions, used on almost every woman in a hospital, which is why it is so concerning that they are not based on data. Whilst I won’t break down the research for each one in this article, let’s take a closer look at one of these interventions in greater detail:

A Case Study:  CTG Fetal Monitoring

CTG (cardiotocograph) is a type of continuous fetal heart rate monitoring that has become ubiquitous in its use in hospitals since its introduction a few decades ago. It involves the woman wearing some bands across her belly, connected to a machine that produces a graph of the woman’s contraction pattern and the fetus’ heart rate. However, this “machine that goes bing!” (Monty Python reference there) was introduced with no evidence to support its claim that  it saves lives or improves the health of babies. Since then, research has not been able to justify its use. In fact, what has been found is that, not only does CTG not save lives, but it leads to far greater rates of C-sections and other interventions, compared to intermittent auscultation (listening every now and again to baby’s heart). 

For women of all risk levels- low risk women, and higher risk women- use of CTG does not reduce perinatal mortality rates for babies (Small et. al. 2019). Further to that, it increases the rate of interventions such as caesarean sections. A recent, Australian study by Levett et. al. (2025) confirmed this discrepancy in our hospitals, but these findings have been known since the first control trial forty years ago (Macdonald et al, 1985), and has been confirmed time and time again. 

It has also been found that clinicians interpret CTGs in a variable and inconsistent way. Research has shown that the variability in these observations occur regardless of the experience of the obstetrician, or their place of work (Hruban et al., 2015). There is evidence that shows that there is quite poor accuracy in determining if a fetus has been deprived of oxygen using CTG (Ben M’Barek, 2024). 

However the use of this technology, and the belief in and reliance on it as a useful tool, persists today in maternity wards. 

WA Health states, in their Cardiotocography Monitoring Policy, that there has been no evidence to show the benefit of CTG on admission during labour, and that using it this may increase the caesarean rate for women in this group by up to 20%. That being said, as I have myself observed, a CTG run of about 20 minutes on admission seems standard at many of our hospitals. In this case, the policy isn’t the issue, the workplace culture is. 

The statement goes on to state that continuous monitoring with CTG is recommended for women with clinical risk factors. The guidelines at King Edward Memorial Hospital, list many risk factors as indication for CTG in their Fetal Heart Rate Monitoring Policy, some of which include women with meconium stained liquor, “delay” in first or second stage of labour (i.e. a long labour), and all women who are choosing a vaginal birth after previous caesarean (VBAC). 

The research discussed above would indicate that in almost all of the listed situations, the use of CTG for these labouring women will likely cause more harm than good.

This is where I get a bit grumpy with the state of things: It has been forty years! There has been so much research! And only last month, the New York Times described CTG as “The Worst Test in Medicine”.

Yet hospitals are still ignoring that the evidence does not show that this monitoring helps babies in these situations. Instead, they’re writing policies based on “that’s what we do here”. The resulting cascade of intervention from an abnormal CTG can be really serious, and even just wearing the bands make movement in labour, and utilising different positions and/or a birthing pool, really difficult. I think women and their babies deserve better.  

An excellent resource for more information on this topic is Dr Kirsten Small’s website. Dr Kirsten Small is a retired obstetrician and gynaechologist, and one of the leading researchers when it comes to fetal monitoring. From her website you can read her research papers, her blog or even take one of her courses for care providers or pregnant women. There is also a series of episodes on this topic on The Great Birth Rebellion Podcast, that looks at the evidence in much more detail than I have here. https://birthsmalltalk.com/   

Policy does not consider long-term health effects for mother and baby

Policy and workplace practices are also designed around outcomes that are experienced during the stay of the mother and baby in hospital. As a reult, sometimes health issues can be “pushed downstream”, with visible health impacts not seen until weeks, months or years later. These effects are not reported on, and do not form part of a hospital’s key performance indicators. Therefore, they often do not form part of the decision-making criteria of policy-writers or clinicians. And, more importantly, women are unaware of the possible unintended consequences of recommendations. 

Below is a table summarising just some examples of tgese effects, their significance and potential causes in the maternity ward. 

Long-term health effect	Why is it significant to the mother-baby diad?	What could be a preventable cause of this?
Breastfeeding success	Affects baby’s long-term health and immunity	Unnecessary* medical interventions (Andrew et al, 2022) Delayed skin-to-skin contact
Long-term poor recovery of the pelvic floor, perineum or surgical sites in the mother	Affects quality of life, mental health and able-bodiness of mothers	Unnecessary* use of induction of labour, episiotomy, forceps, vacuum or C-Section. Coached pushing.
Postnatal anxiety, depression or PTSD	Has direct wellbeing implications for the mother. Has been shown to have a large effect on the child’s development throughout life.	Care that is not consensual, trauma-informed or humane. Unnecessary separation of mother and baby. Delayed skin-to-skin contact.  Unnecessary* medical interventions.
Gut biome and immunity development of the child	Higher incidence of autoimmune issues, such as asthma, and allergies in the child. Most cases of illness in childhood.	Prophylactic antibiotics given to mothers during labour. Prophylactic antibiotics given to babies after birth. Unnecessary* C-Section

*”Unneccessary” is the context here means something recommended without good medical indications.

Here is an example I have experience with: Hospital policy often recommends an induction for “postdates” (usually at 41 weeks + 3 days), to mitigate the risk of stillbirth, which increases from about 0.1% at 41 weeks to 0.3% at 42 weeks (Muglu et al, 2019). This is recommended even when the woman and baby are healthy, and it is up to clinicians to advise women of the risks and benefits in the application of this policy. However, in my own experience, I was not advised of the evidence demonstrating that induction is strongly related to high rates of emergency c-section, poorer breastfeeding success, higher rates of perineal trauma and poorer mental health outcomes for mothers.   

Hospital Staff are Beholden to Hospital Policy and Influenced by Workplace Culture 

No one shows up to work in a hospital with the intention to disrupt a woman’s labour or cause her trauma. However, OBs, midwives and NICU staff are all required to uphold a range of different rules in order to protect themselves from litigation and to protect their livelihoods. Sometimes those rules are written, and sometimes they are unwritten, cultural practices. I have heard anecdotes of workplace bullying directed at clinicians who are trying to apply their knowledge when it goes against the status quo. It’s a sad reality for many birth workers, and a likely contributor to the high rate of midwifery burnout. 

Hospital is not the only option!

As I stated at the beginning of this article, big organisations need policy and procedure. Whilst there is much to be done to fix the current ones, that work will take time, and lots of champions of change.

The good news is that, if this concerns you, hospital may not be your only option to birth under the care of health care professionals. Having chosen to have my baby at home, under the care of endorsed midwives, I was so impressed with the level of nuance that they were able to apply in the recommendations they made for me, my wellbeing, and my birth. Whilst they, too, have protocols and standards of care from their governing body, they have a shorter list of stakeholders to please. And the woman, and her family, rank much higher in their list. 

Read on to discover more about the EXTRAORDINARY care provided by continuity of care with a midwife.

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Keep Reading: Reason #5 Continuity of Care with A Midwife is the Gold Standard

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