Stevie Elliot, with 16-month-old Sunny, underwent an emergency C-section to have her daughter. Photo / Mark Mitchell
Three in every 10 babies are born via caesarean section in New Zealand - an all-time high. But are Kiwi women being given the right information and can our healthcare system provide the care they need, asks Rebecca Haszard.
Stevie Elliot was a first-time mother-to-be with a plan. She wanted a “natural” home birth and did everything she could to prepare for that: hypnobirthing, calm birth courses, meditation, research.
But as it turned out, Elliot underwent an emergency C-section to have her daughter, Sunny, after a 36-hour labour and two hours of attempting a vaginal birth.
“A C-section wasn’t even in my periphery,” says the Wellington-based mother of the major abdominal surgery that can see women experiencing issues years down the track and is often and unfairly considered “the easy way out”.
While she tells the Herald her midwifery and medical team “were amazing”, she was left shocked by the lingering issues following her procedure and what she felt was a lack of postpartum care once she finished up with her midwife.
Now 16 months post-birth, Elliot says she’s experienced numbness and pulling sensations around her scar and other issues she didn’t expect given she didn’t have a vaginal birth.
The former brand and product designer has a weakened pelvic floor, pain in her coccyx, which she is seeing a chiropractor for, diastasis recti – separation of the abdominal muscles - and for eight months after her daughter’s birth, plantar fascia – extreme pain in her feet.
Elliot says she received more care after breaking her finger than she did following her C-section, considered a major abdominal surgery.
“With that [finger] recovery I had four months of hand rehabilitation covered by ACC.
“That’s why it shocked me so much that once I was out of care from my midwife at the six-week mark, when I was ready to begin thinking about rebuilding my body, it’s like, you’re on your own.”
The number of C-sections in New Zealand has risen by 5.45 per cent in the past 11 years and is currently at the highest-ever recorded rate, making up about 30 per cent of births, according to data from Te Whatu Ora.
The World Health Organisation also suggests if current trends continue, by 2030 C-sections could make up 45 per cent of births across Australia and New Zealand.
C-sections have previously caused controversy at Auckland City Hospital where, in 2020, due to high rates, the hospital stopped allowing more private obstetricians to access birthing facilities.
The ban was lifted but in April, the Herald reported the hospital had put stricter rules on new private obstetricians, which were slammed as “inappropriate” by the Auckland Association of Private Obstetricians.
Initial recovery from a caesarean requires about two to three days in hospital post-birth - longer than a vaginal birth without complications. The recovery period of at least six weeks is also generally longer. In this time the advice is to avoid driving and not lift anything heavier than the weight of your baby.
Midwife care runs through the first six weeks postpartum before mother and baby come under the care of Plunket or Tamariki Ora. A GP visit also takes place at six weeks for baby’s first immunisations.
The list of birth injuries ACC covers is now up for review. Elliot was not eligible for ACC cover but looked into seeing a pelvic floor specialist in the first six months after the birth of her daughter. But she was prohibited by the cost, especially because she and her fiance, Darcy Frankin, were down to one income.
“Fifteen months later, I’ve finally booked in to see one,” says Elliot who wants to see subsidised rehabilitation for all postpartum care.
“Like a pregnancy WOF for mums with pelvic floor physiotherapy, so we at least know where we are at with our after-birth bodies and how we can start to rebuild them and what that looks like.”
She recalls being given PDFs while in hospital but beyond that did her own “rehab and research”, which also led her to develop a scar massage oil, “belly birth” ice packs and healing spray as part of her postpartum care range Viva La Vulva. The range is now used by pelvic floor physiotherapists.
Senior pelvic floor physiotherapist Renee Malyon, who spent 11 years working in the UK and Middle East before returning to New Zealand where she now practices at Auckland Physiotherapy, says she has seen an increase in women who have had caesareans presenting with ongoing issues.
Part of that may be due to what she observes as a “disconnect” in care for C-section women.
“It’s just a big misconception that women are taking the easy way out. And it’s so frustrating and hurtful because it’s not. It is a major abdominal surgery and it’s a slow recovery.
“There seems to be a disconnect between that kind of full spectrum of care for the fourth trimester. It’s really disheartening. People just aren’t being referred to get checked with a pelvic physio or other support practitioners. Maybe it’s that people aren’t aware …”
She says, “Whether an abdominal birth is elective or emergency, aftercare is still very much warranted. There just seems to be this misconception that C-sections affect women quite early on, but the reality is the symptoms can continue for years after that if left.”
Malyon is seeing women “a year or two years down the line with pain and issues with their scars, tummy separation and weakness. Some can even have pelvic floor dysfunction. There’s surprise there but there’s also disappointment because they feel like if they’d known they would have come earlier.”
And she sees women with “repeated C-sections and that may have [impacted] bladder function, so they can sometimes present with urgency or frequency, emptying issues or incontinence. Or the nervous system: nerves grow back so slowly in the area that women can have a lack of sensation. And it can often cause biomechanical dysfunction in terms of other joints, because of the disconnect of your core deep abdominal muscles, and that can lead to back pain, hip pain, knee pain.”
She says the impact can be beyond physical too.
“When I have a client say their C-section is affecting every aspect of their life, I wholeheartedly believe it because the mental health side of it is so profound. Clients will often replay what they could have done differently. It’s that whole mindset: disappointment, failure and worthiness,” says Malyon, who is also a certified mindfulness teacher and somatic trauma therapist.
“We try and help support them as much as possible from an emotional perspective.
“I’ll be looking at their scar and their stomach and getting them to reconnect with their scar and the tears always flow. I always have tissues on hand. It’s to really hold that space for a woman that they’ve never actually addressed.”
In fact, a lot of women Malyon sees have never touched their scars.
“I might be the first person who teaches them what to do and this can be months to years down the line when women have no idea what that scar could be impacting,” says Malyon, who founded Haven Wellness and co-founded the online platform Rising Mother to provide workshops for mums working through all four trimesters and beyond.
“Unfortunately, I’m just not seeing them soon enough and they don’t realise - they’re not being told. Or potentially people are being told but they don’t really understand the implications. Or, obviously having a baby is really life-changing and you’re in survival mode for the first three months if not more, so women probably put it to the side.
“It’s a bit of that Kiwi mindset, ‘Oh, just get on with it. She’ll be right,’ type thing.”
What needs to change is early referrals being made by midwives, obstetricians and GPs, she says, noting some women seek her out in private practice rather than wait to be seen in the public system where wait times are known to be long.
“It’s to improve the connection and encourage early referral. When I lived in the Middle East I had several obstetricians’ phone numbers and we would chat about clients and they would refer them on. So that kind of relationship was there. I feel this could be improved between midwives or obstetricians and allied health care professionals.”
She also notes that in France it’s standard that a woman sees a pelvic floor physio post-birth.
“My goal is for every woman to feel supported and educated and empowered on their healing journey with a wholistic and multidisciplinary approach,” says Malyon, who works alongside her Auckland Physiotherapy colleague and Rising Mother co-founder Vanessa Werner, a birth doula, prenatal educator and postpartum counsellor, and naturopath Emma Gardiner, who helps with digestive and bowel issues that can occur after a C-section.
Malyon advises seeing a pelvic health physio postpartum “at six weeks at least, then three months and six to nine months, just to get checked because sometimes things can come on later. It may not be straight away. It may be down the track.”
Elliot is one of thousands of Kiwi women experiencing ongoing issues since giving birth who is not eligible for ACC cover, either due to when they gave birth or the cause of their symptoms.
While ACC’s birth injury coverage has now been in effect since October 2022, injuries on its list must be sustained due to “a force or resistance internal to the human body at any time from the onset of labour to the completion of delivery”. According to a document listing the “Cost of Treatment Regulations”, ACC will pay up to $75.66 an hour for physiotherapy.
ACC’s acting chief clinical officer, Dr Dilky Rasiah, says the list is up for review “to make sure it is adequate”, and this could begin in November.
Associate Minister of Health, Willow-Jean Prime, tells the Herald that there are no immediate plans to review C-section and postpartum care in New Zealand.
She says the ACC changes “were designed to support [birthing people] in that recovery” and that “assistance might be needed straight away after the birth of a baby while they’re in the hospital, or sometime after birth when it’s been identified they need further support and care for their injury”.
She says when a condition is not covered by ACC, a birthing person is “encouraged to talk to their midwife, doctor or primary care provider about support available, which may include a referral to a private physiotherapist or to their local gynaecology service”.
Dr Emma Jackson, clinical director of obstetrics and gynaecology at Te Whatu Ora, Waitaha (Canterbury), agrees women need to know there are options for rehabilitation and they should be made aware of their options post-birth.
“I think women need to know that they can see a pelvic floor physio for rehabilitation, and it can be a proactive step rather than when they find themselves having significant problems.”
But like Malyon, she acknowledges there isn’t currently a standard “comprehensive screening” or postnatal pelvic floor assessment available.
“There isn’t a really comprehensive screening right across the board or a detailed assessment of the pelvic floor postnatally. Lead maternity carers aren’t specifically trained to assess a woman’s pelvic floor as it’s not within their frame of standard training or within their normal remit.
“Although they will obviously be looking at, how is your scar healing, how are you feeling, and they’ll look at any problems with the scar healing. That’s quite different than a kind of proactive rehabilitation programme.”
In a statement from Te Tatau o te Whare Kahu, New Zealand’s Midwifery Council, current guidelines “enable midwives to refer birthing people to a physio for pelvic floor care at any time during pregnancy and up to six weeks post birth.
“Midwives can also lodge ACC claims within their scope of practice for birthing parents in their care who experience a maternal birth injury. Midwives can make referrals within the six-week postpartum period, and do so, or direct women to self-refer to a pelvic physio.”
However, it is noted there is “often delay to publicly funded physiotherapy and not all women can afford a pelvic physio privately”. Midwife referrals to maternity physios may be covered by ACC.
Jackson also explains a pelvic floor assessment doesn’t sit under the remit of a GP either.
“A lot of people talk about this lost opportunity at the six-week check for the GP to pick it up and there’s this kind of whole thing that people talk about, ‘Oh, the GP check has the focus more on the pēpi,’ and the main reason is that the current GP six-week check is purely funded to provide baby immunisations. GPs are not funded to provide a free-to-user maternal postnatal check-up, assessment and wellbeing check, or contraceptive provisions, so would have to charge a large co-payment to the parent for this.”
She notes there is also a shortage of GPs and many practices have wait times of up to six weeks or more for routine appointments.
“All of these issues can make it more complex for the postnatal patient looking to seek advice and assessment for symptoms following a birth.”
Jackson was a representative for RANZCOG (Royal Australian and New Zealand College of Obstetricians and Gynaecologists) on the perineal injury clinical expert advisory group assisting ACC from 2019 to 2020. She was also one of the experts consulted by the Ministry of Business, Innovation and Employment regarding the proposed list of covered birth injuries in 2021.
Currently a New Zealand council member for RANZCOG, she tells the Herald seeing ACC birth injury forms given to every birthing person who has had stitching or suturing while they are still in hospital would be advantageous in people being aware of their injuries and having a clear avenue to being seen from the beginning.
“Initially the advice was that [health professionals] don’t need to complete ACC forms for everybody. But I think the problem for most birthing parents is they then don’t know if they have or will have cover from the outset for their injuries and their care.
“It means it complicates the ability to seek help if there is a problem. But it also means that they don’t seek proactive input such as advised education about rehabilitation and recovery and an assessment when they just have symptoms that might be seen as more minor and be put down to, ‘Oh, that’s just normal after having a baby.’ It might be a sign of something that with early intervention you could actually benefit from pelvic floor physiotherapy or advice for other interventions.”
Beyond when someone makes an ACC claim, Jackson says there are challenges to accessing postpartum care, due to current legislation and the strain on New Zealand’s healthcare system.
“We would like to think that the public system is able to provide care for everybody to meet their health needs.
“But we know that there are a number of women not making the threshold for care currently.”
She says even if all women did, many of New Zealand’s hospitals don’t have the ability to provide that care.
“We haven’t increased our capacity in the public system to meet what was previously an unmet need that is now partly funded by ACC.”
She points out that limitations in the public system vary depending on the hospital, but it is acknowledged that wait times are long for gynaecology patients.
“In Waitaha at the moment, we’re not accepting referrals from GPs to our specialist clinic to see a gynaecologist for benign conditions. It’s been closed for a number of months and will likely be closed until the end of the year.
“Parents with birthing complications who couldn’t afford an [ACC] co-payment and need to see a gynaecologist, they will have a long wait at the moment,” she says of those who may have qualified for coverage for a birthing injury.
At Christchurch Hospital, as of the week of July 17, Jackson says in gynaecology 414 patients were waiting for a first appointment with a specialist, with 230 of these waiting more than 120 days. And 635 patients were on the waiting list for gynaecology surgeries, of whom 218 have been waiting more than 120 days.
Elliot says after her birth and postpartum experience, she’s become “a big believer that if we go into labour and postpartum armed with education, the less traumatic our birth experiences can be. I know this would’ve been the case for me.”
And she says the care must go “beyond physical recovery too. [It] transcends into mental health - if mothers are equipped to deal with that initial postpartum stage or fourth trimester, this sets the foundation of how they will thrive in motherhood. If our mothers are supported - everyone benefits.”
Rebecca Haszard is a senior lifestyle and entertainment writer, co-host of the Herald’s parenting podcast One Day You’ll Thank Me and a former digital and magazine editor, including Girlfriend magazine.
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