Even in the safest country in the world, birth is a risk
Karin Vosmansky had expected her first pregnancy would end in a natural birth and "a beautiful, Anne Geddes baby". "Instead," the Melbourne mother says, "I had a general anaesthetic, drugs galore and a baby that looked like a skinned rabbit, attached to 60 million tubes."
Thirty-two weeks into her pregnancy, she was taken by ambulance to the Mercy Hospital in Melbourne for an emergency caesarean that ended with her and her son in intensive care.
Vosmansky had become so sick with pre-eclampsia and HELLP syndrome, which can cause haemorrhage and liver damage, that her body had begun to shut down. She was prepped for theatre while still on the ambulance trolley.
"My husband had to deal with it all," Vosmansky says. "[Baby] Robbie was in the neonatal unit and he started out OK, but then he crashed and they decided they had to ventilate him so they kicked Michael out, and then there was me with tubes to kingdom come."
She felt unwell from the start of her pregnancy, but just before Christmas 2006, her doctor became concerned.
"I started to puff up and my blood pressure started to rise. My doctor put me on medication and said we'll have to see what happens here. It was a first-time pregnancy so I was not really aware of what that meant."
About a month later, her doctor called and told her to get to hospital. Her test results had come back and something was wrong. When she got to the Angliss Hospital in Ferntree Gully she was told she was too sick for them. They rang around Melbourne to find intensive care beds for her and for her as-yet-unborn son and transferred her to the Mercy.
"I knew I was in trouble then ... My central nervous system was shutting down, so they put me under to stop me having seizures ... another 24 hours and we both would have been dead."
Vosmansky spent two weeks in hospital recovering. Robbie was allowed home after six weeks. It took more than a year for her liver function tests to return to normal.
For the birth of daughter Isabella three years ago, Vosmansky was closely monitored from the start of her pregnancy. She was hospitalised with pre-eclampsia again but managed to hold off until 37 weeks to give birth, and neither mother nor baby suffered any complications afterwards.
To help her come to terms with what had happened, Vosmansky helped establish a support group, Life's Little Treasures Foundation, and she now helps women who find themselves in similar situations. "Having a premature baby is something that stays with you forever. It has a massive impact on your life. We have women whose child is 14 or 15 come to see us because they still need to talk about what happened. You just don't think it will happen to you."
Australia is one of the safest countries in the world in which to give birth - for the 300,000 or so babies born each year, about 20 mothers will die in the process. This compares with about 1100 in every 100,000 mothers in Chad.
Yet ill health among expectant and new mothers is rising, according to the Australian Institute of Health and Welfare. Problems mothers face include serious conditions such as Vosmanksy's pre-eclampsia, as well as complications arising from medical interventions down to more minor ailments such as urinary tract infections.
Researchers put the rise in health problems down to factors including older mothers, more obesity and more caesarean sections (the rate has almost doubled in the past 20 years to 32 per cent of pregnancies in Australia - the World Health Organisation recommends a rate of between 10 and 15 per cent).
Haemorrhage, a major cause of maternal death, has also increased significantly over the past 15 to 20 years, a problem that has been identified across the developed world, although nobody is really sure why. About seven in every 100 women in Australia will haemorrhage after giving birth.
But for all the bad news stories about pregnancy and childbirth, there are thousands of good ones. While health problems are on the rise, most Australian women give birth naturally, without intervention. The vast majority survive the experience and receive proper care before and after the births of their children.
While mothers in developing countries die from haemorrhage, sepsis, obstructed labour and disorders caused by high blood pressure - the same conditions that are on the rise in Australia but can be treated here - women in Australia face a different set of problems. They include complications arising from medical interventions, mental health issues and health system failures.
"Suicide is one of the leading causes of women dying after childbirth in the developed world," says Hannah Dahlen, a University of Western Sydney midwifery professor and spokeswoman for the Australian College of Midwives. "The biggest [maternal] death rate is nine to 12 months after birth and it's because of suicide and death by violent means." Dahlen is about to publish a UWS study into maternal deaths in Australia up to a year after birth.
She says mental health disorders and drug and alcohol abuse are key factors in the suicide rate among mothers. But she says the rate is also a reflection of a model of care that is not providing enough social and psychological support for mothers.
"One in 10 women are coming out of childbirth traumatised, with post-traumatic stress disorder. That's a real worry," she says. "If you are coming out of childbirth feeling devastated, like a failure, unable to get on with life, those interactions with your baby are fundamentally wiring that baby's brain and there are psychological implications for children."
Symptoms of postnatal depression, which can become a debilitating and persisting illness, can begin anywhere from 24 hours to several months after delivery. Panda, the Post and Antenatal Depression Association, says it may affect not just the new mother but those around her, including men.
Caroline Anderson flew from Warren, in central western NSW, to Sydney for the birth of her third child, Digby, in 2001.
The 37-year-old had an epidural and a caesarean and spent a week at Prince of Wales Private Hospital before being discharged on a weekend and flying home. She was discharged even though she had bad back pain, which she first complained about on the second day after giving birth.
It was the result of an epidural abscess, an infection in her spine resulting from the epidural.
After getting home, she developed a headache and temperature and was admitted to Dubbo Base Hospital. She was discharged without the abscess being detected, even though her obstetrician in Sydney had told the registrar to check for one.
About a week later, her family took her back to hospital, this time in Warren, but it was too late. She was transferred back to Dubbo, then on to Liverpool Hospital, where she died, three weeks after giving birth.
Her brother, Mike Anderson, a pharmacist, says that the fact his sister lived in a regional area did not play a big role in her death - she had picked up the infection in Sydney and had been discharged there, despite being unwell.
He says the main reasons his sister died were inadequate infection control, inadequate note-taking by hospital staff in Sydney and Dubbo and communication breakdowns.
"You really need an advocate when you go into hospital to make sure there is continuity of care ... an individual to take charge of responsibility for the patient, rather than handing someone on to somebody else.
"Unless someone is looking after you from the beginning, warning bells don't ring.
"A lot of the issues are as relevant today as they were 12 years ago, when Caroline died.
"They use Caroline's case to train midwives and young doctors now, which at least is a positive thing for us."