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Understanding and measuring emotion could be key to cultural safety in maternity care

Why cultural safety matters in maternity care

In Australia, the chance of dying or being unwell around the time of birth is higher for Aboriginal and Torres Strait Islander mothers and babies than non-Indigenous peoples (Australian Institute of Health and Welfare, 2020). Health professionals need to understand that racism fundamentally determines these health outcomes (Paradies et al., 2015). Institutionalised racism occurs when racism is hidden in the governance, policies, and practices of the organisation – in ways that work best for some groups and worse for others. One of the reasons Aboriginal and Torres Strait Islander families may avoid maternity care is that they do not feel safe or respected (Sivertsen et al., 2020). In part, this is because the western, biomedical approach to healthcare is at odds with Aboriginal and Torres Strait Islander holistic approaches to birth and birthing practices. These holistic approaches recognise the intricate relationships mothers and babies have to Country. There is a national drive for Birthing on Country, to provide Aboriginal and Torres Strait Islander families with a holistic, integrated and culturally safe model of care that supports the best start in life (Molly Wardaguga Research Centre, 2019).

Learning culturally safe practice

Recognising that institutional racism underpins Australian healthcare, has sparked new ways of teaching and learning to promote health equity and social justice. Indeed, midwives must learn to practice in culturally safe ways when working with Aboriginal and Torres Strait Islander families and communities. This requirement has been mandated by Aboriginal and Torres Strait Islander leaders and peak professional bodies (Australian Nursing and Midwifery Council (ANMAC), 2017; Australian Health Professional Regulation Agency (AHPRA), 2018). But learning cultural safety learning is not just about understanding Aboriginal and Torres Strait Islander culture, outcomes and social determinants of health. Primarily, it is about how non-Indigenous health students grapple with institutional racism within the healthcare system and critically reflect on their role within it.

Why emotion impacts learning cultural safety

Students react in different ways when learning cultural safety content. Some may begin to adopt anti-oppressive practice quickly, while others can become defiant, or experience significant emotional adversity. Non-Indigenous students may lack knowledge of the effects of settler colonialism and/or feel that their social identity is being challenged. This may lead to emotional reactions that are complex, and often semi-conscious. As students work through these emotional experiences, protective mechanisms (such as outward displays of anger) may arise. Alternatively, students may become caught in feelings of guilt and shame (Mills and Creedy, 2019). Becoming ‘stuck’ in these emotions reinforces inertia and preserves the status quo. Staying stuck makes institutional racism difficult to address in any meaningful way. Despite the complexity of teaching and learning in cultural safety, research about students’ complex emotional reactions has been rare.

Measuring emotion

Our research team developed and tested a survey tool to understand non-Indigenous student emotional learning experiences in cultural safety education (Mills, Creedy, Sunderland & Allen, 2021). The tool, named the Student Emotional Learning in Cultural Safety Instrument (SELCSI), is First Peoples-led with two scales of measurement: witnessing and comfort. The SELCSI was tested with 109 nursing and midwifery students after finishing a semester-long cultural safety course. Our results showed that the SELCSI is a valid and reliable measure of emotion in cultural safety education. In addition, the comfort scale can be used to support students to reflect on their level of comfort with cultural safety content. For educators, the scale can be used to see how students are sitting with the content to enable them to adapt to students’ needs.

Where to from here

Understanding and measuring non-Indigenous students’ emotions when learning cultural safety will support student reflection and learning. At the same time, it will promote responsive and innovative approaches to cultural safety education. Significantly, measuring emotion using the SELCSI may be fundamental to culturally safe health practice. Cultural safety is required to achieve health equity for Aboriginal and Torres Strait Islander peoples.

References

Australian Health Practitioner Regulation Agency (AHPRA). (2018). Aboriginal and Torres Strait Islander Health Strategy – Statement of Intent. https://www.ahpra.gov.au/About-AHPRA/Aboriginal-and-Torres-Strait-Islander-Health-Strategy/Statement-of-intent.aspx

Australian Institute of Health and Welfare. (2020). Australia’s Mothers and Babies 2018 – In Brief. Canberra: AIHW.

Australian Nursing and Midwifery Accreditation Council (ANMAC). (2017). Enrolled Nurse Accreditation Standards 2017. https://www.anmac.org.au/sites/default/files/documents/ANMAC_EN_Standards_web.pdf

Mills, K., & Creedy, D. (2019). The ‘Pedagogy of discomfort’: A qualitative exploration of non-indigenous student learning in a First Peoples health course. The Australian Journal of Indigenous Education, 1-9. https://doi.org/10.1017/jie.2019.16

Mills, K., Creedy, D. K., Sunderland, N., & Allen, J. (2021). Examining the transformative potential of emotion in education: A new measure of nursing and midwifery students’ emotional learning in first peoples’ cultural safety. Nurse Education Today, 104854. https://doi.org/10.1016/j.nedt.2021.104854

Molly Wardaguga Research Centre. (2019). Birthing on Country. Retrieved from www.birthingoncountry.com

Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gee, G., 2015. Racism as a determinant of health: a systematic review and meta-analysis. PLoS One 10 (9), e0138511.

Sivertsen, N., Anikeeva, O., Deverix, J., & Grant, J. (2020). Aboriginal and Torres Strait Islander family access to continuity of health care services in the first 1000 days of life: a systematic review of the literature. BMC Health Serv Res, 20(1), 829. https://doi.org/10.1186/s12913-020-05673-w

The two most common reasons women have a first caesarean section

 

Research in context

In Australia and many high-income countries, the rate of caesarean section (CS) is increasing. There is no evidence that higher rates of CS improve health outcomes, which raises concerns about overuse of the surgical procedure (ACOG et al., 2014).

In 2000, 1 in 5 Australian women had a caesarean section. That rate is now more than 1 in 3 (AIHW, 2018). For women having their first baby in Australia the risk of CS is 37% (AIHW, 2020). Once a woman has experienced a CS, future vaginal birth is much less likely. In Australia, 7 out of 8 women will have a repeat CS for their next baby (AIHW, 2020). Therefore, preventing the first caesarean section (called a “primary CS”) is paramount wherever safely possible (ACOG et al., 2014).

Some have attributed the significant rise in CS rates to the increase in older and more obese pregnant women (RANZCOGAIHW releases data on caesarean section in Australia). Indeed, age ≥35 years and obesity can increase the chances of health issues including high blood pressure, diabetes, and multiple pregnancies. Nevertheless, this change alone is unlikely to explain the magnitude of the rise in CS rates, nor the differences in CS rates in different settings (WHO, 2018).

What the research did 

New research led by PhD candidate Haylee Fox, supervised by TMCC Deputy-Director, Associate Professor Emily Callander, aimed to build our knowledge in this area: https://onlinelibrary.wiley.com/doi/full/10.1111/birt.12530

Fox et al. (2021) used routinely collected hospital data to analyse the main reasons recorded by clinicians for primary CS in Queensland Health hospitals. Nearly 100,000 women either having their first baby or having a subsequent baby after previous vaginal birth were included in the study. Women who had experienced a previous CS were excluded.

What the research found

The top two reasons women in Queensland public hospitals had a primary CS were: ‘abnormal fetal heart rate’ (23%) and ’primary inadequate contractions’ (23%). Medical interventions including artificial rupture of membranes (ARM), oxytocin augmentation or induction of labour, and epidural analgesia predicted CS for fetal heart rate concerns (as did obstructed labour). Where a primary CS was performed due to “inadequate” contractions, epidural analgesia, ARM, fetal stress, and oxytocin augmentation or induction were predictive factors.

So what does this mean?

Induction of labour and epidural analgesia predict the two most common reasons for primary CS.  Accurate, evidence-based information about the potential consequences of induction of labour or epidural should be provided to all women (Fox et al, 2021). Indeed, these results warrant professional reflection on the use of induction of labour and epidural analgesia, alongside critical review of relevant policies, given the clear link with primary CS.

An Australian study including 1.25 million reported women who accessed birth centre or homebirth had lower rates of oxytocin augmentation and epidural use. Maternal and perinatal outcomes by planned place of birth in Australia 2000 – 2012: a linked population data study | BMJ Open. The Cochrane systematic review found women receiving midwife-led care in a hospital setting were less likely to receive an epidural, although it appeared to make no difference to rates of induction of labour or oxytocin augmentation. Midwife-led continuity models of care compared with other models of care for women during pregnancy, birth and early parenting | Cochrane

Midwifery continuity of care models and out-of-hospital birth protect against overuse of medical interventions including CS. Universal access to continuity of midwifery care should be a national policy priority.

References

American College of Obstetricians and Gynecologists (College); Society for Maternal-Fetal Medicine, Caughey AB, Cahill AG, Guise JM, Rouse DJ. (2014). Safe prevention of the primary cesarean delivery. American Journal of Obstetrics and Gynecology, 210(3), 179-93. https://doi.10.1016/j.ajog.2014.01.026

Australian Institute of Health and Welfare. (2020). Australia’s Mothers and Babies 2018 – In Brief. AIHW.

Fox, H., Topp, S. M., Lindsay, D., & Callander, E. (2021). A cascade of interventions: A classification tree analysis of the determinants of primary cesareans in Australian public hospitals. Birth: Issues in Perinatal Care, 00, 1-12. https://doi.org/10.1111/birt.12530

Homer, C.S.E., Cheah, S.L., Rossiter, C. et al. (2019). Maternal and perinatal outcomes by planned place of birth in Australia 2000 – 2012: a linked population data study. BMJ Open, 9, e029192. https://doi.10.1136/bmjopen-2019-029192

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD004667. https://doi.10.1002/14651858.CD004667.pub5

World Health Organization. (2018). WHO Recommendations Non-Clinical Interventions to Reduce Unnecessary Caesarean Sections. WHO.

Preterm birth and the cost to women

When a baby is born preterm, they are more likely to face significant health challenges. As a consequence, the care they receive is more expensive than a baby born around term. Some of this cost is met by government funding, but not all. Women who give birth to preterm babies provide the bulk of the care for preterm babies during their first years of life, and therefore incur most of these cost shortfalls. Just how much this amounts to is a question that has recently been addressed (Fox & Callander, 2021).

Ms Haylee Fox from James Cook University and Associate Professor Emily Callander, a Transforming Maternity Care Collaborative member, set out to determine both the out-of-pocket health care costs women who have recently given birth face, and the loss of income incurred as a consequence of a delayed return to employment. They did this for women who gave birth at term, and those who gave birth preterm so any differences could be measured. Data from the Longitudinal Study of Australian Children and the Maternity 1000 dataset were used to provide answers.

Women who gave birth preterm took longer to return to employment (2.8 years) than women who gave at term (1.9 years). Mothers of preterm babies were more likely to not return to paid employment at all, while those who did had a lower income than women who gave birth at term. Out of pocket healthcare expenses were $1059 for women who gave birth at term, $1298 for women who gave birth between 32 and 36 weeks, and $2491 for those who gave birth at less than 32 weeks.

It has long been recognised that being born preterm does not provide the optimum start to life. Fox and Callander’s research suggests that financial hardship is likely to compound the health challenges preterm children face during early childhood. They have demonstrated that preterm birth limits women’s capacity to participate in the workforce. While ensuring adequate government income support for new mothers is an important step in rectifying the financial shortfall, interventions to prevent preterm birth are likely to be far more cost effective and assist women to re-enter the workforce in a timely manner.

Midwifery led continuity of care is backed by sound evidence demonstrating both a reduction in preterm birth and lower mortality rates related to this (Medley et al., 2018). Implementation of continuity models has been found to be cost neutral, however the research to date has not considered the potential impact of changes to downstream costs from a reduction in preterm birth (Sandall et al., 2016). Access to continuity of midwifery care models remains below demand for such services (Donnellan-Fernandez et al., 2020). Addressing barriers to accessing such models should be a priority focus for policy makers.

References

Donnellan-Fernandez, R. E., Creedy, D. K., Callander, E. J., Gamble, J., & Toohill, J. (2020, Aug 28). Differential access to continuity of midwifery care in Queensland, Australia. Australian Health Review, 45(1), 28-35. https://doi.org/10.1071/AH19264

Fox, H., & Callander, E. (2021, Jan 10). Cost of preterm birth to Australian mothers: Assessing the financial impact of a birth outcome with an increasing prevalence. Journal of Paediatrics and Child Health, in press. https://doi.org/10.1111/jpc.15278

Medley, N., Vogel, J. P., Care, A., & Alfirevic, Z. (2018, Nov 14). Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews. Cochrane Database of Systematic Reviews, 11, CD012505. https://doi.org/10.1002/14651858.CD012505.pub2

Sandall, J., Coxon, K., Mackintosh, N., Rayment-Jones, H., Locock, L., & Page, L. A. (2016). Relationships: the pathway to safe, high-quality maternity care.

Making continuity of care experiences work for midwifery students

There has been an expansion in research focussed on how best to prepare midwifery students for practice over recent years. In Australia and many other high-income countries, a key component of pre-registration education is the completion of continuity of care experiences. During these continuity experiences, midwifery students participate in the care of an individual woman across multiple antenatal visits, during her labour, and through the postpartum period. This requires students to recruit women and remain on-call for them over an extended period, which is challenging for many. It is therefore important to ensure that continuity of care experiences provide valuable learning experiences for students.

Moncrieff et al. (2021) recently reviewed the published literature, asking what the evidence says about how to optimise students’ learning during continuity experiences. The research team identified twelve studies which helped to address this question, all but one of which was undertaken in Australia. The value of continuity experiences as an educational tool was clear. Three main themes were described:

1. Relationships.
Relationships with women, midwifery mentors, and other clinicians were central to students learning. Ensuring that attending appointments with women was a priority and structuring the curriculum around this in ways that supported sustainable study practices for students facilitated the development of relationships with women. Having continuity of placement site and mentor also enhanced relationship-based learning.

2. Conflict or coherence.
Providing continuity within a fragmented model of care was challenging, with better quality learning occurring when students were placed in continuity of care models.

3. Setting the standards.
Unclear communication with students regarding the purpose, numbers, management, and documentation of continuity experiences generated confusion for students. When clear guidance, flexible program delivery, and appropriate assessment were provided, students were enabled to develop confidence and competence.

In completing this literature review, the authors highlighted the absence of a solid evidence base to underpin the intent and design of continuity experiences for midwifery students. Since their review was completed, further evidence to support the benefits of placing students in continuity models has been published (Baird et al., 2021). There remain many opportunities to pursue further research that seeks to ensure that midwifery students graduate with the confidence and competence required to take up a productive role in a midwifery continuity of care program.

References

Baird, K., Hastie, C. R., Stanton, P., & Gamble, J. (2021). Learning to be a midwife: Midwifery students’ experiences of an extended placement within a midwifery group practice. Women and Birth, in press. https://doi.org/10.1016/j.wombi.2021.01.002

Moncrieff, G., MacVicar, S., Norris, G., & Hollins Martin, C. J. (2021, Feb). Optimising the continuity experiences of student midwives: an integrative review. Women Birth, 34(1), 77-86. https://doi.org/10.1016/j.wombi.2020.01.007

Bundles for perineal care: the impact on midwifery practice

When attempting to solve difficult problems in healthcare, professional organisations are increasingly making use of bundled approaches to care. A care bundle consists of collection of interventions which are believed to work interactively to address the issue in question. Using several interventions at once, at a whole of population level, is considered to be a more effective approach than the application of single interventions. There is however little evidence to support this assumption (Lavallee et al., 2017).

In maternity care, severe perineal trauma (sometimes called obstetric anal sphincter injury or OASI) is an issue that has received attention in both the United Kingdom and Australia. Tearing of the tissues at the opening of the vagina is common at birth. Typically, these tears are small and heal well without impacting on the function of the pelvic floor. Less often, tearing can be more extensive and extend to include the muscles around the anus (categorised as a third-degree tear) or into the anal passage (categorised as a fourth-degree tear). Trauma involving the anal sphincter muscles and / or anal passage can result in long term problems controlling the passage of wind and bowel movements. Recognising the extent of the trauma is important, as appropriate surgical repair and physiotherapy enhances the likelihood of restoring the normal function of the muscles.

Concerns have been raised that severe perineal trauma has become more common in recent years, though some argue that it is simply that clinicians have become better at recognising when it has occurred (Thornton & Dahlen, 2020). A bundle designed to prevent and identify severe perineal trauma was introduced in the United Kingdom in 2016 (Gurol-Urganci et al., 2021) in the hope that the rate of severe perineal trauma might be reduced. Another perineal care bundle was introduced in Australia in 2018 (Women’s Healthcare Australasia, 2019), with slight differences to the interventions included. In Australia the bundle consisted of:

  • Applying warm compresses to the perineum during birth
  • Applying manual pressure to the fetal head and the woman’s perineum during birth
  • Performing an episiotomy (a cut made at the opening of the vagina) for all women giving birth for the first time when instrumental birth is being conducted (vacuum extraction or forceps assisted birth), and when an episiotomy is done, ensuring that the angle of incision is at least 60 degrees from the vertical
  • All women having two people assess their perineum after vaginal birth, and
  • This assessment included a digital rectal examination, even when the perineum appeared intact.

High quality research evidence is only available for the first of these practices (Aasheim et al., 2017). Outcomes from the United Kingdom perineal bundle were reported after the Australian bundle was rolled out (Gurol-Urganci et al., 2021), finding a small but statistically significant reduction in the incidence of severe perineal trauma, occurring in 3 less women per 1000 following the introduction of the bundle. What is not known is how the bundle impacts on midwifery practice nor has there been research to understand the bundle from the perspective of birthing women.

Recently published research from Transforming Maternity Care Collaborative researchers Dr Jyai Allen, Dr Kirsten Small, and Dr Nigel Lee of the University of Queensland set out to examine the impact that the Australia perineal bundle had on midwifery practice (Allen et al., 2021).

Midwives working in Queensland hospitals where the bundle had been introduced were recruited, with twelve midwives from five hospitals being interviewed. Midwives were asked about the approaches to perineal care they used prior to the introduction of the bundle and how this had changed with the introduction of the bundle. The findings were presented relating to three themes:

  1. Design and implementation of the bundle,
  2. Changes to midwifery practice, and
  3. Obstetric domination and midwifery submission.

Participants expressed confusion about whether the bundle was a research project or a quality improvement measure. Emotive appeals rather than the presentation of sound evidence for the elements of the bundle was used in education sessions supporting the introduction of the bundle. Some midwives readily accepted all the changes to practice that occurred with the introduction of the bundle, with others used a variety of approaches to “get around” aspects of the bundle they considered inappropriate. When midwives did comply with all elements of the bundle there was a sense that this was done from a position of relative powerlessness to provide alternative approaches to practice.

Midwives described concerns about the standardising effects of the bundle, which prevented them from being able to provide individualised care. The practices outlined in the bundle were considered easiest to apply when women had an epidural and were confined to bed for birth. Meeting the bundle requirements (particularly maintaining manual perineal support) was not always possible when approaches such as waterbirth or upright, forward leaning postures where used. Midwives were concerned that the bundle therefore favoured forms of care (such as restricting women to the bed for birth) which made it easier to comply with the bundle requirements.

Overall, the bundle appeared to reflect and reinforce technocratic obstetric ways of knowing and acting. Midwives were therefore placed in a position where they were required to frame their practices in relation to an obstetric view of the ideal approach to preventing severe perineal trauma. Providing care consistent with midwifery philosophy, such as individualised care that supports physiological processes would be seen as non-compliant behaviour. To avoid this, future bundle development should include consultation and collaboration with women and midwives, and routine evaluation of the bundle should include research to examine the impact of the bundle on midwifery practice and women’s experiences of their births.

References

Aasheim, V., Nilsen, A. B. V., Reinar, L. M., & Lukasse, M. (2017). Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews, 6, CD006672. https://doi.org/10.1002/14651858.CD006672.pub3

Allen, J., Small, K., & Lee, N. (2021, Jan 20). How a perineal care bundle impacts midwifery practice in Australian maternity hospitals: A critical, reflexive thematic analysis. Women and Birth, in press. https://doi.org/10.1016/j.wombi.2021.01.012

Gurol-Urganci, I., Bidwell, P., Sevdalis, N., Silverton, L., Novis, V., Freeman, R., Hellyer, A., van der Meulen, J., & Thakar, R. (2021). Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury: a multicentre study with a stepped-wedge design. British Journal of Obstetrics and Gynaecology, 128(3), 584-592. https://doi.org/10.1111/1471-0528.16396

Lavallee, J. F., Gray, T. A., Dumville, J., Russell, W., & Cullum, N. (2017). The effects of care bundles on patient outcomes: a systematic review and meta-analysis. Implementation Science, 12(1), 142. https://doi.org/10.1186/s13012-017-0670-0

Thornton, J. G., & Dahlen, H. G. (2020). The UK Obstetric Anal Sphincter Injury (OASI) Care Bundle: A critical review. Midwifery, 90, 102801. https://doi.org/10.1016/j.midw.2020.102801

Women’s Healthcare Australasia. (2019). The how to guide: WHA CEC perineal protection bundle. https://women.wcha.asn.au/sites/default/files/docs/wha_national_collaborative_how_to_guide_21.1.20.pdf

 

Preparing students to provide continuity of care

Continuity of midwifery care provides superior maternal and neonatal outcomes (Sandall et al., 2016). Access to continuity of care models is limited, both for women and for midwifery students who have the opportunity to gain direct experience of such models. There is also concern that placing students in a continuity of care model rather than a standard hospital model of care may reduce their learning.

New research from Professor Kathleen Baird, Ms Carolyn Hastie, Ms Paula Stanton and Emeritus Professor Jenny Gamble of the Transforming Maternity Care Collaborative focussed on the learning experiences of students who complete an extended placement in a midwifery group practice providing continuity of care at Griffith University (Baird et al., 2021). Final year midwifery students were able to elect to take part in a six-month placement in a midwifery group practice team. The research team conducted focus group interviews to explore the experiences of fifteen students who had taken part in the placement.

Students reported that their placement in the midwifery group practice was the highlight of their degree and was not as demanding as they had anticipated. Being able to develop skills in providing relationship-based care was highly valued by students and was enabled and supported by the midwives they were working with. The culture of the midwifery group practice in which students were placed provided a supportive environment were students learned to take care of themselves and their team members, and to collaborate with other members of the team. Students felt that they were valued members of the team. Returning back to the hospital shift-based system was challenging for most students. They were aware of a loss of autonomy and a faster pace of care. Some were supported well in this transition, while others were criticised for their choice to spend time in the midwifery group practice.

This research enables midwifery educators to be confident that prolonged immersive student placements in midwifery continuity of care models provides positive learning experiences. The students described feeling and acting like a “real midwife” during their placement, with six being adamant that they would apply for a position in a midwifery group practice immediately after graduation. Increased access to midwifery continuity of care models for women would provide more opportunities for midwifery students to gain experience of working in this model.

References

Baird, K., Hastie, C. R., Stanton, P., & Gamble, J. (2021). Learning to be a midwife: Midwifery students’ experiences of an extended placement within a midwifery group practice. Women and Birth, in press.

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016, Apr 28). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, 4(11), CD004667.

The Transforming Maternity Care Collaborative continues to grow

A Collaborative is as strong as the people who contribute to it. The Transforming Maternity Care Collaborative continues to grow. We recently welcomed four new Project Leads who bring their personal strengths to the team.

Professor Rhona McInnes – Director of Practice Translation

Professor Rhona McInnes

Professor Rhona McInnes is a Professor of Maternal and Child Health in Queensland. Rhona recently relocated from Scotland where she led a realist evaluation of the implementation of a continuity of care model at one health board in Scotland. Her research has contributed to the international body of knowledge relating to infant feeding and maternal and child health; focusing primarily on how decisions and health outcomes are affected by individual and organisational behaviours situated within their socioeconomic and political context (including healthcare service structures). Through her research she aims to advance strengths-based, salutogenic approaches that ultimately reduce health inequalities.

Rhona is currently evaluating the response of maternity and child health services to providing care during COVID19 with the aim of ensuring access to high quality care and informing preparedness for future large-scale event. She is also developing a programme of research that aligns with the First 2000-days and with high-value care.

As Director of Practice Translation, Rhona aims to ensure that evidence-based practice and women-centred care are at the core of maternity and child health services. To do this she is taking a strategic approach to strengthening evidence-based practice and identifying clinically relevant research opportunities. Sustaining high-quality care requires research capacity and capability within the health service, which means that it is important to identify and mentor early career researchers and clinical practitioners. Rhona welcomes opportunities to work with others to grow skilled research capacity and progress research and innovation within the maternal and child health space.

Associate Professor Lois McKellar – Director of Education

Associate Professor Lois McKellar

Education of the future maternity workforce plays a key role in the transformation of maternity care. Lois McKellar is an Associate Professor of Midwifery based in South Australia and has recently taken up the position of Director of Education for the Transforming Maternity Care Collaborative. She is an advocate for working collaboratively to ensure the provision of outstanding midwifery education and equipping midwives for practice in the 21st century and beyond. Lois is a Fellow of the Governor’s Leadership Foundation and a founding member and the current chair of the Trans-Tasman Midwifery Education Consortium (TTMEC).

Lois has been recognised for her excellence in teaching with an Office for Learning and Teaching award acknowledging her work in developing a sustainable model of support for midwifery students learning through continuity of care experiences. In 2019, Lois engaged with the International Confederation of Midwives and international colleagues to develop a national midwifery curriculum for WHO India.  Lois’ current research responds to the priorities for midwifery education as identified through the TTMEC Delphi study. With specific focus on increasing visibility of midwifery, mentoring of midwifery students and evaluating the clinical practice component of their education.

The Transforming Maternity Care Collaborative provides a mechanism to embed midwifery education as a critical component influencing quality maternity care.  Promoting the distinctiveness of midwifery education is vital to support the increase and sustainability of midwifery models of care. Lois brings a strong focus on research that underpins education pedagogy and practice, as well as a focus on strengthening midwifery academics.

Dr Zoe Bradfield – Co-Director Health Promotion

Dr Zoe Bradfield

Dr Zoe Bradfield is a midwifery academic and Research Fellow in Western Australia. Zoe is a vibrant midwifery leader, delivering excellence in education, research, and professional leadership. Her research strengths are based her understanding of the transformative power of quality maternity care which has fuelled her passion for inspiring excellence in health practitioners and leading innovative translational research that contributes to better outcomes for women, their families, and society.

Her recent research has focussed on what it means for midwives to be “with woman” in their practice, leading to a collaboration which has undertaken the development of a tool to measure woman-centred care. Zoe is currently leading a team of multidisciplinary researchers to explore the impact of COVID-19 on the key stakeholders of maternity care in Australia. She shares the role of Co-Director of the Health Promotion program for the Transforming Maternity Care Collaborative with Professor Debra Creedy.

The Health Promotion Program has 3 key priorities: to develop and test interventions that facilitate the health and wellbeing of mothers and babies; enable women to achieve the best possible health outcomes by improving health literacy; and develop and test strategies that enable health professionals, services and sectors to collaborate effectively to produce optimal outcomes for women and babies.

Dr Christine Catling – Director of Workforce

Dr Christine Catling

Associate Professor Christine Catling is a midwifery academic and an NHMRC Fellow at the University of Technology Sydney. She is also the Co-lead of the Maternal, Newborn and Women’s Clinical Academic Group, for the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE). She has been a midwife for over 25 years, both in the UK and Australia.
A/Prof Catling has extensive experience in antenatal education, policy development and research, and has published on workforce issues, homebirth, vaginal birth after caesarean section, maternal mortality, vaginal breech birth, maternal and child health in Papua New Guinea, simulation-based learning and vitamin D levels in mothers and neonates. In 2015 she was the inaugural research fellow for the World Health Organization Collaborating Centre at UTS. Her PhD explored the influences on women who chose a publicly-funded home birth in Australia, and current work focusses on the workplace culture in midwifery.

A/Prof Catling believes research, innovation and good quality midwifery are pivotal to the well-being of mothers and young families. Her NHMRC Fellowship (2021-2025) focuses on the midwifery workplace culture, examining the use of regular Group Clinical Supervision for midwives.

As Director of Workforce, Christine aims to create a passionate group with a shared philosophy that work together to support midwives to do the physically, intellectually and emotionally challenging job they signed up for. This group aims to consist of midwifery researchers with an interest in helping to retain the workforce and making midwives’ workplaces a more collegial, caring and supportive environment.

Are you interesting in learning more or contributing to the Transforming Maternity Care Collaborative?

Please make contact with us so we can explore how we can work with you to help transform maternity care. We send out a regular newsletter. Complete our contact form and let us know if you would like to be added to the distribution list for this. You can also follow us on Twitter or LinkedIn.

Midwifery students and birthing women: a valuable relationship

Women value midwifery students and midwifery students value women. One Australian university has begun to collect routine, ongoing, web-based feedback from all women who complete a continuity of care experience (CCE) with a midwifery student. Analysis of the first 12 months of data found that women value CCE with student midwives and midwifery students are providing above and beyond the minimum requirements for care. Continuity of midwifery care (CMC) has long been recognised as the cornerstone of quality midwifery care but how does this manifest in pre-registration midwifery programs?

CCE was introduced to Australian pre-registration midwifery programs as a way to provide students “experience in woman-centred care” (ANMAC, 2015, p. 24). Currently Australian midwifery students must support a minimum of 10 women within a CCE including a minimum of four antenatal visits, attendance at the majority of women’s labour and births as well as a minimum of two postnatal visits (ANMAC, 2015). The number of CCE students are required to undertake has been reviewed periodically by accreditation board ANMAC since 2010 and has reduced from a total of 30 in 2010 to the current 10 (Teirney et al., 2018). Some midwifery students and accredited midwifery education providers have previously argued that they have found complexities when managing clinical placements, CCE experiences, assessment, course requirements, employment and family responsibilities (Gray et al., 2013; McLaughlan et al., 2013). It was thought that reducing the number of total CCE would provide a higher quality of CCE experiences for students and women (ANMAC, 2014).

Although minimum requirements of a Bachelor of Midwifery (BMid) program at one Australian university are double the number (20) of minimum CCE and a minimum of five antenatal visits, all labour and births, and three postnatal visits (to six weeks postpartum), a recent study has shown that midwifery students at this university provide women even more support than this (Tickle et al., 2020). Students in this program completed a mean average of 5.83 antenatal visits, attended 92.6 percent of women’s labour and births and a provided a mean average of six postnatal contacts. The authors state that the midwifery program in this study is flexible in its design to privilege the CCE (Tickle et al., 2020). This may have allowed students to prioritise women’s care where necessary.

From previous statements made regarding the reduction of CCE requirements with intention to increase the quality of a CCE, you may be mistaken for believing that although student attendance in this study was high, the quality of the experience for women was lacking, however this is untrue. The study, where 57 percent of women provided feedback, found that the majority of women were satisfied with the student in the antenatal period (86.6 percent), labour and birth (86.4 percent) and postnatally (79 percent) (Tickle et al., 2020). Women were more satisfied when their CCE student attended their labour and birth (Tickle et al., 2020). Additionally, there was a positive correlation between a woman’s level of satisfaction and respect (measured on standardised scales) and the number of antenatal visits and postnatal contacts midwifery students had with women (Tickle et al., 2020). Nearly all women would recommend a midwifery student (97.6 percent) (Tickle et al., 2020). It could be argued that in order for the original purpose of the introduction of CCE by ANMAC (to provide experience in woman-centred care) to be fully realised, women should remain at the centre of a CCE. Women clearly value their midwifery student providing CCE and therefore the authors recommend midwifery standards be revised to increase both the total number and minimum requirements of CCE  for pre-registration midwifery students (Tickle et al., 2020).

Providing all women the opportunity to feedback their experiences gives women a voice and exemplifies respectful, woman-centred, professional practice. Feedback from women affords students and faculty a unique perspective for reflection, practice and program review and revision to help ensure women remain at the centre of learning and teaching in midwifery.

For women to receive continuity of midwifery care the midwifery workforce requires midwives to work within continuity models (Gamble et al., 2020). Midwifery students placed in CMC models are more likely to want to work in these models after graduation (Carter et al, 2015; Cummins et al., 2017). Over one third (34.7 percent) of women in the Tickle et al. (2020) study received a midwifery continuity primary model of care meaning that many students are being exposed to CMC models which may contribute to a growing CMC workforce.

CCE is important for women, students and the future midwifery workforce. Increasing pre-registration midwifery program standards to include a larger number of CCE, increased minimum requirements, routine feedback from women and maintaining quality is both feasible and optimal. In the same way women’s satisfaction with a midwifery student providing CCE echoes current research with midwives providing CMC (Sandall et al., 2016), it is possible clinical outcomes for women receiving a CCE will follow the same trajectory.

References

Australian Nursing and Midwifery Accreditation Council. (2014). Midwife accreditation standards. ANMAC. https://www.anmac.org.au/sites/default/files/documents/ANMAC_Midwife_Accreditation_Standards_2014.pdf

Carter, A., Wilkes, E., Gamble, J., Sidebotham, & Creedy, D.K. (2015). Midwifery students׳ experiences of an innovative clinical placement model embedded within midwifery continuity of care in Australia, Midwifery, 31(8), 765. https://doi.org/10.1016/j.midw.2015.04.006

Cummins, A.M., Denney-Wilson, E., & Homer, C.S.E. (2017). The mentoring experiences of new graduate midwives working within midwifery continuity of care models in Australia. Nurse Education in Practice, 24, 106-111. https://doi.org/10.1016/j.nepr.2016.01.003

Gamble, J., Sidebotham, M., Gilkison, A., David, D. & Sweet, L. (2020). Acknowledging the primacy of continuity of care experiences in midwifery education. Women and Birth, 33(2), 111-118. https://doi.org/10.1016/j.wombi.2019.09.002

Gray, J., Leap, N., Sheehy, A. & Homer, C.S. (2013). Students’ perceptions of the follow-through experience in 3 year bachelor of midwifery programmes in Australia. Midwifery, 29(4), 400-406. https://doi.org/10.1016/j.midw.2012.07.015

McLachlan, H.L., Newton, M., Nightingale, H., Morrow, J., Kruger, G. (2013). Exploring the ‘follow-through experience’: a statewide survey of midwifery students and academics conducted in Victoria, Australia. Midwifery, 29(9), 1064-1072. https://doi.org/10.1016/j.midw.2012.12.017

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, 4. https://doi.org/ 10.1002/14651858.CD004667.pub5

Tickle N., Gamble J. & Creedy DK. (2020) Women’s reports of satisfaction and respect with continuity of midwifery care experiences by students: Findings from a routine, online survey. Women & Birth, in press. doi.org/10.1016/j.wombi.2020.11.004

Tierney, O., Sweet, L., Houston, D. & Ebert, L. (2018). A historical account of the governance of midwifery education Australia and the evolution of the continuity of care experience. Women and Birth, 31(210-215). https://doi.org/10.1016/j.wombi.2017.09.009

VBAC: How risk perception contributes to the caesarean section rate. An opinion piece.

During the final year of the Bachelor of Midwifery at Griffith University, midwifery students are asked to write an opinion piece focussed on normal birth that could be published. Dr Jyai Allen convenes this course and supported the students to complete this work. Several of these were of such good quality that we offered students the option of having them published here. This is the final one of five articles in a series. The author of this article preferred to publish anonymously. 

The current caesarean section birth rate in Australia is approximately 34% (Australian Institute of Health and Welfare [AIHW], 2019). After a caesarean section, most Australian women choose to have an elective caesarean section for subsequent births, with only 12-13% of women choosing to attempt a vaginal birth after caesarean section (VBAC) (Meredith & Hugill, 2016). The reason for this seems to be the perceived risks of VBAC as opposed to an elective caesarean, with the primary concern for women being an increased risk of uterine rupture (Black et al., 2016). Repeat elective caesarean births contribute to Australia’s high caesarean section rate, far above the World Health Organization’s recommendation based on evidence that caesarean section rates over 10% do not improve health outcomes. Given that the success rate for vaginal birth after caesarean section is 72-75%, increasing to 85-90% for women who have had a vaginal birth before (Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2019), the question can be asked why the VBAC attempt rate is so low, considering the risks of this type of birth is low.

Birth has biological, cultural, social, and political influences (Behruzi et al., 2013). Socially, birth is shaped by the society women live in, with culture, social class, and resources contributing to decision-making (Behruzi et al. 2013). Research shows that decisions regarding the mode of birth are partially influenced by discussions of birth stories with other women, which often focus on negative aspects and experiences of their births (Latifnejad Roudsari et al., 2015). Social conformity also influences birth and birth choices, with values and ideas of women often reflecting the views of those around them, including family, friends and health professionals (Behruzi, et al., 2013). In a society and country where birth primarily takes places in a medicalised environment where maternity care providers are influenced by medical culture, these views can be projected onto women in a direct or indirect way. This is certainly true during consultation and provision of information regarding mode of birth after caesarean section, with evidence showing that both direct and subtle influences by maternity care providers greatly impacting women’s decisions on mode of birth (Black et al., 2016). How statistics and information are presented to women alters their perception of risk, with VBAC often being perceived by woman as much more risky than in actuality (Meredith & Hugill, 2016).

Medicalisation of birth is an issue that women and midwives are constantly contending with while trying to achieve normal birth. Medical models of birth take a risk-based approach that assumes birth to be risky and leads women to believe that these risks can be managed and reduced with the aid of medical technology (Cummins, 2020). Media contributes to the medicalisation of birth, as most portrayals of birth in film and television are overly medicalised. While most women might be consciously aware that these depictions of birth are not factual nor a reality, it has been shown that media representations of birth are subconsciously still informing women and providing them with expectations (Cummins, 2020). With this expectation that birth should be medically managed, trust in birth decreases and women are more easily influenced into birth interventions. Research also shows that births portrayed in film and television generates fear of birth and this affects the birth choices made by women (Luce et al., 2016). Takeshita (2017) finds that as well as creating fear of birth, media trivialises women’s capacity to give birth and overlooks midwifery. Collectively this contributes to the culture of birth in Australia, where many women and families consider birth to be considerably risky. In a birth culture focused on risk, perception of risk can be disproportionate to actual risk and this is apparent when looking at the low rates of VBAC in Australia.

One way to help combat these socio-cultural issues is through provision of an antenatal care environment that is encouraging of active participation by the woman in care and discussions (Chen et al., 2019). This is especially important for women making decisions on mode of birth after a caesarean section and improves the VBAC attempt rate (Chen et al., 2019). Continuity of care with a known midwife would be the ideal model of care for active participation and holistic conversation, however fragmented care is still the norm in maternity care in Australia. Women planning VBAC who had continuity of care with a midwife felt more in control of decision- making, more confident, and more supported than those who received fragmented care or care with a doctor (Keedle et al., 2020). Midwives have a professional obligation to promote normal birth (Australian College of Midwives [ACM], 2018). However, midwives also acknowledge the necessity to remove bias when presenting women with evidence-based information and this can lead them to omit the positive aspects of vaginal birth. When providing information on VBAC, midwives should present evidence to women on both the actual risk of VBAC as well as risks associated with caesarean section birth. In addition to this, in order to promote holistic health and wellbeing, midwives should also discuss the positive benefits of vaginal birth for women and babies, rather than focusing solely on the risks of both modes of birth. According to women seeking VBAC this in not demonstrated in practice, with communication being mostly risk-orientated (Nilsson et al., 2017). In a culture that is both risk adverse and reliant on technology, failing to highlight the benefits of normal birth focusses on risk and women are more inclined to choose a medicalised technocratic approach to birth (Behruzi, 2013). Understanding social attitudes about birth is important to foster a positive understanding and attitude towards vaginal birth, in order to decrease population caesarean section rates and promote health (Latifnejad Roudsari et al., 2015). Thus fulfils midwives’ professional standards to promote health and wellbeing by identifying what is important to women as the foundation for using evidence to promote informed decision-making, participation in care, and self-determination (ACM, 2018).

Analysis of successful VBAC in countries with high VBAC rates has confirmed the importance of provision of information in a supportive manner, understanding of benefits of VBAC, the support of trusting maternity care provider during birth, letting go of past negative birth experiences, and viewing VBAC as the goal when no other complications are present (Nilsson et al., 2017). Continuity of care with a midwife for women would help all of these factors associated with increased VBAC rate. Given the low risk involved in VBAC for most women, midwives and doctors can have confidence in recommending and supporting VBAC to change the default mode of birth after caesarean section from a repeat caesarean to VBAC.

References 

Australian College of Midwives. (2018). Midwife standards for practice. Retrieved from https://www.nursingmidwiferyboard.gov.au/documents/default.aspx?record=WD18%2f252 81&dbid=AP&chksum=kYbO0%2bO7kx9I%2fBlvmKH%2bwg%3d%3d

Australian Institute of Health and Welfare. (2019). National Core Maternity Indicators. https://www.aihw.gov.au/reports/per/095/ncmi-data-visualisations/contents/labour- birth/b5

Behruzi, R., Hatem, M., Goulet, L., Fraser, W., & Misago, C. (2013). Understanding childbirth practices as an organizational cultural phenomenon: A conceptual framework. BMC Pregnancy and Childbirth, 13(1), 205. doi:10.1186/1471-2393-13-205

Black, M., Entwistle, V. A., Bhattacharya, S., & Gillies, K. (2016). Vaginal birth after caesarean section: Why is the uptake so low? Insights from a meta-ethnographic synthesis of women’s accounts of their birth choices. BMJ Open, 6(1), e008881. doi:10.1136/bmjopen-2015- 008881

Chen, M. M., McKellar, L., & Pincombe, J. (2017). Influences on vaginal birth after caesarean section: a qualitative study of Taiwanese women. Women and Birth, 30(2), e132-e139. doi:1016/j.wombi.2016.10.009

Cummins, M. W. (2020). Miracles and home births: The importance of media representations of birth. Critical Studies in Media Communication, 37(1), 85-96. doi:10.1080/15295036.2019.1704037

Keedle, H., Peters, L., Schmied, V., Burns, E., Keedle, W., & Dahlen, H. G. (2020). Women’s experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia. BMC Pregnancy and Childbirth, 20(1), 1-15. doi:10.1186/s12884-020-03075-8

Latifnejad Roudsari, R., Zakerihamidi, M., & Merghati Khoei, E. (2015). Socio-cultural beliefs, values and traditions regarding women’s preferred mode of birth in the north of Iran. International Journal of Community Based Nursing and Midwifery, 3(3), 165-176.

Luce, A., Cash, M., Hundley, V., Cheyne, H., van Teijlingen, E., & Angell, C. (2016). “Is it realistic?” the portrayal of pregnancy and childbirth in the media. BMC Pregnancy and Childbirth, 16(1), 40. doi:10.1186/s12884-016-0827-x

Meredith, D., & Hugill, K. (2016). ‘Once a caesarean, always a caesarean’? Challenging perceptions around vaginal birth after caesarean. British Journal of Midwifery, 24(9), 616-623.

Nilsson, C., van Limbeek, E., Vehvilainen-Julkunen, K., & Lundgren, I. (2017). Vaginal birth after caesarean: Views of women from countries with high VBAC rates. Qualitative Health Research, 27(3), 325-340. doi:10.1177/1049732315612041

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2019). Birth after previous caesarean section. https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Birth-after-previous-Caesarean-Section-(C-Obs-38)Review-March-2019.pdf?ext=.pdf

Takeshita, C. (2017). Countering technocracy: “Natural” birth in The Business of Being Born and Call the Midwife. Feminist Media Studies, 17(3), 332-346. doi:10.1080/14680777.2017.1283341

No Pain, No Gain? An opinion piece

During the final year of the Bachelor of Midwifery at Griffith University, midwifery students are asked to write an opinion piece focussed on normal birth that could be published. Dr Jyai Allen convenes this course and supported the students to complete this work. Several of these were of such good quality that we offered students the option of having them published here. This is the fourth articles in a series of five. This article was written by Monique Matthews.

No Pain, No Gain?

Many women express wanting a ‘drug free labour’ or a ‘natural/normal birth’. The International Confederation of Midwives (ICM) definition of normal birth, requires the process to occur without any surgical, medical, or pharmacological intervention.

Pharmacological pain relief are interventions that include, epidural, opioids (morphine) and nitrous oxide (happy gas). Women not using pharmacological pain relief have many options. These include heat, hydrotherapy/water immersion (shower/bath), acupressure and acupuncture, hypnosis, relaxation, breathing, massage, yoga, transcutaneous electrical nerve stimulation (TENS), aromatherapy, sterile water injections, and a birth ball. These techniques are termed non-pharmacological pain relief.

In 2018 in Australia, 21% of women exclusively used only non-pharmacological pain relief, whereas, 78% of women used pharmacological pain relief during labour. With a high rate of pharmacological pain relief and the known negative impacts of these techniques, the question needs to be asked: why have non-pharmacological techniques, that are less invasive and more natural, become the alternative rather than the standard option?

History

Techniques for pain relief in labour have changed throughout history, largely influenced by their availability and the values of practitioners. The earliest techniques were midwifery based, which facilitated the natural physiology of labour in the home with family support and only intervened in life threatening difficulties. Many of these non-pharmacological techniques are still used today.

In the early 1700s birth moved from midwifery to obstetrics as formal biomedical training started institutionalising birth in the hospital. Doctors perspectives became greatly influential. Doctor Joseph Lee likened women’s experience of childbirth to falling on a pitchfork and he wanted to rid childbirth of “unskilled” labour assistance. This enforced the idea that women were unable to cope with labour pain and they required professional help to survive. Pain became a target of medical intervention.

Pain relief techniques in labour through the 1800s and 1900s introduced pharmacological pain relief such as chloroform, nitrous oxide and a mixture of morphine (pain relief) and scolimeine (memory loss) coined ‘twilight sleep’. Women were barely conscious while giving birth, dehumanising the process and causing extensive trauma. In the 1960s, epidural pain relief gained popularity. An interest in returning to non-pharmacological birthing practices also emerged around this time, as the experience of pain was considered empowering for women. By 1990, women’s rights to pain relief were again promoted for a technological, pain free birth.

Today, the primary healthcare provider for a woman in labour in Australia can be a doctor or midwife. Women’s views on what techniques they will use during labour are diverse, as they are impacted by their social and cultural learning, the media, and the ongoing medicalisation of birth.

Biomedical Paradigm

While the ICM’s definition of normal birth excludes the use of pharmacological intervention, the Queensland Clinical Guidelines definition includes the use of nitrous oxide, normalising pharmacological pain relief. Within the guideline the term ‘non-pharmacological support’ is consistently used. This situates these techniques within a biomedical paradigm, with risk and pathology as the dominant discourse. This implies that these natural and traditional techniques are inferior, by stating that they are ‘other’ than the dominant pharmacological techniques.

This position is often supported in media representations where women are unrealistically shown lying on a bed, out of control, screaming for pain relief. Today, this is a more common source of information than having been present at an actual birth. The expectations women form, impact their experience of pain as it is a subjective experience, influenced by social and cultural learnings.

Physiological vs medical approaches to pain

When women experience uterine contractions, the pain is physiological rather than pathological. This pain is considered beneficial, as it emphasises the need for support, heightens elation and triggers hormones to support wellbeing. During labour, women naturally produce hormones (oxytocin and endorphins) that counter the intensity of the pain experienced. Stress hormones (catecholamines and cortisol) can override this natural pain relief when women experience fear or a lack of trust. If women and midwives understand these hormonal processes and use non-pharmacological techniques to enhance them, the fear cascade can be avoided.

If labour pain is a subjective experience, why is a medical approach, based on objective principles, used?

The biomedical paradigm views birth as a mechanical process requiring intervention for efficacy and safety. Using pharmacological pain relief changes labour from a physiological process to a medical procedure as side effects require management.

Nitrous oxide can cause nausea, vomiting, dizziness, and drowsiness. Morphine crosses the placenta lowering the baby’s breathing rate and alertness at birth. Women can also experience excessive sedation, a lowered breathing rate and nausea. Epidurals increase instrumental vaginal birth rates by 500% and can increase the use of synthetic oxytocin, length of labour, low blood pressure, and a less positive birth experience.

As non-pharmacological techniques have less side effects, why are they not better promoted? The answer may lie in the cost effectiveness of these techniques, which do not make manufacturers as much money, causing them to be understudied, which lessens practitioner’s confidence in the techniques. Sara Wickham articulates this point well when she said “Ethically, medical intervention has to prove itself against nature. Not the other way around”.

Power Play

Women can be empowered during their birth experience through woman-led, self-generating techniques that involve partners. However, pharmacological pain relief shifts power from the woman to the practitioner. This phenomenon occurs as standard monitoring is required to deem whether the situation is ‘safe’ to continue labour, creating parameters that may exclude women from decisions.

The power of suggestion can impact which techniques women use during labour. If midwives and practitioners are afraid of being with women in pain, they may offer increased pain relief when they feel the woman needs it, rather than upon request. Women have described feeling coerced and being presented with false dilemmas with limited choices. Consent is not valid in these situations if the risks of pharmacological pain relief are not fully disclosed, or the information is tailored by midwives. Research on epidurals, found they are sometimes used as a substitute for continuous support.

This raises the question: Is pain relief used more often for the convenience of practitioners, rather than to meet the needs of women?

Pain relief is a human right!

Access to pain relief is considered a human right. Some women accessing maternity care may state that they want an epidural immediately or make the decision to use pharmacological pain relief when they were not initially planning to. This is their right. However, pain perception is influenced by social and cultural learnings, medicalisation, and the media. This may not include evidence-based information on birth physiology and adequate support for non-pharmacological pain relief techniques.

A study on pain relief in labour found epidurals were considered the most effective pain relief, nonetheless, water birth was associated with higher levels of satisfaction than epidural use. Predictors for a positive birth experience include a positive attitude and support from midwives, ability to mobilise, confidence & autonomy, inclusion of partners and a safe birthing environment. Birth satisfaction does not solely depend on the level of pain experienced, but the care provided. Women’s autonomy is promoted when non-pharmacological techniques are appropriately explained and used.

Reframing non-pharmacological pain relief

Non-pharmacological pain relief needs to be reconceptualised. Labour is not a problem to be solved but an experience to be worked through. Non-pharmacological techniques enhance this experience and most are easily implemented, affordable, and effective in helping women and their partners actively engage in their care. Midwives, as the protectors of normal birth, should be confident to inform, promote and facilitate the use of non-pharmacological techniques during labour.

Pain relief techniques offered to women during labour are influenced by the opinions and values of their care provider. A mindset change in the way midwives and practitioners present choices to women could increase understanding of the benefits of non-pharmacological pain relief in labour. Discussing non-pharmacological pain relief options not defined by the medical paradigm, but rather, validated in their own right, could improve women’s confidence in their labour choices. Using words such as intuitive or natural techniques would be more appropriate.

Women’s decisions are influenced by social and cultural norms. Birthing choices can be positively influenced, by providing information around birthing techniques based on evidence, that focuses on women’s needs. Comprehensive discussion during antenatal care of physiology in labour and all of the pain relief techniques available, including the risks and benefits, would ensure women are adequately informed.

Current labour care is not always focused on women’s needs. Social and cultural learnings from media sources informed by a biomedical paradigm have influenced midwives and women to discount the benefits of non-pharmacological pain relief. Pharmacological pain relief techniques are being used in a majority of births without necessarily providing the best experiences. Non-pharmacological pain relief techniques, which have been effective since traditional midwifery care, enhance the physiological process, support women’s autonomy and can facilitate a positive birth.

So, I challenge you, instead of questioning whether non-pharmacological pain relief techniques are adequate labour care, question whether all pain relief techniques are being adequately facilitated and ask – who is benefiting from these choices?

References

Abdul-Sattar Khudhur Ali, S., & Mirkhan Ahmed, H. (2018, 2018/06/01/). Effect of change in position and back massage on pain perception during first stage of labor. Pain Management Nursing, 19(3), 288-294. https://doi.org/https://doi.org/10.1016/j.pmn.2018.01.006

Amiri, P., Mirghafourvand, M., Esmaeilpour, K., Kamalifard, M., & Ivanbagha, R. (2019). The effect of distraction techniques on pain and stress during labor: a randomized controlled clinical trial. BMC Pregnancy and Childbirth, 19(1), 1-9. https://doi.org/10.1186/s12884-019-2683-y

Aune, I., Brøtmet, S., Grytskog, K. H., & Sperstad, E. B. (2020). Epidurals during normal labour and birth — Midwives’ attitudes and experiences. Women and Birth, in press. https://doi.org/https://doi.org/10.1016/j.wombi.2020.08.001

Australian College of Midwives. (2016). Scope of Practice for Midwives in Australia. https://www.midwives.org.au/sites/default/files/uploaded-content/field_f_content_file/acm_scope_of_practice_for_midwives_in_australia_v2.1.pdf

Bonapace, J., Gagné, G.-P., Chaillet, N., Gagnon, R., Hébert, E., & Buckley, S. (2018). No. 355-Physiologic basis of pain in labour and delivery: An evidence-based approach to its management. Journal of Obstetrics and Gynaecology Canada, 40(2), 227-245. https://doi.org/10.1016/j.jogc.2017.08.003

Brennan, F., Carr, D., & Cousins, M. (2016). Access to pain management—Still very much a human right. Pain Medicine, 17(10), 1785-1789. https://doi.org/10.1093/pm/pnw222

Czech, I., Fuchs, P., Fuchs, A., Lorek, M., Tobolska-Lorek, D., Drosdzol-Cop, A., & Sikora, J. (2018). Pharmacological and non-pharmacological methods of labour pain relief—Establishment of effectiveness and comparison. International Journal of Environmental Research and Public Health, 15(12), 2792. https://doi.org/10.3390/ijerph15122792

Fockler, M. E., Ladhani, N. N. N., Watson, J., & Barrett, J. F. R. (2017, 2017/06/01/). Pregnancy subsequent to stillbirth: Medical and psychosocial aspects of care. Seminars in Fetal and Neonatal Medicine, 22(3), 186-192. https://doi.org/https://doi.org/10.1016/j.siny.2017.02.004

Gönenç, İ. M., & Dikmen, H. A. (2020, 2020/03/01/). Effects of dance and music on pain and fear during childbirth. Journal of Obstetric, Gynecologic & Neonatal Nursing, 49(2), 144-153. https://doi.org/https://doi.org/10.1016/j.jogn.2019.12.005

Happel-Parkins, A., & Azim, K. A. (2016). At pains to consent: A narrative inquiry into women’s attempts of natural childbirth. Women and Birth, 29(4), 310-320. https://doi.org/10.1016/j.wombi.2015.11.004

Health, A. I. o., & Welfare. (2020). Australia’s mothers and babies 2018—in brief. https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-and-babies-2018-in-brief

International Confederation of Midwives. (2014). Position Statement: Keeping Birth Normal. https://www.internationalmidwives.org/assets/files/statement-files/2018/04/keeping-birth-normal-eng.pdf

Keedle, H., Schmied, V., Burns, E., & Dahlen, H. G. (2019). A narrative analysis of women’s experiences of planning a vaginal birth after caesarean (VBAC) in Australia using critical feminist theory. BMC Pregnancy and Childbirth, 19(1), 142-115. https://doi.org/10.1186/s12884-019-2297-4

Luce, A., Cash, M., Hundley, V., Cheyne, H., van Teijlingen, E., & Angell, C. (2016, 2016/02/29). “Is it realistic?” the portrayal of pregnancy and childbirth in the media. BMC Pregnancy and Childbirth, 16(1), 40. https://doi.org/10.1186/s12884-016-0827-x

Lundgren, I., Healy, P., Carroll, M., Begley, C., Matterne, A., Gross, M. M., Grylka-Baeschlin, S., Nicoletti, J., Morano, S., Nilsson, C., Lalor, J., Sahlgrenska, a., Göteborgs, u., Gothenburg, U., Institutionen för vårdvetenskap och, h., Institute of, H., Care, S., & Sahlgrenska, A. (2016). Clinicians’ views of factors of importance for improving the rate of VBAC (vaginal birth after caesarean section): a study from countries with low VBAC rates. BMC Pregnancy and Childbirth, 16(1), 350. https://doi.org/10.1186/s12884-016-1144-0

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