Enablers and barriers to the reform of maternity services
Study 1 – Power and technology
Research evidence does not support the widespread use of intrapartum CTG monitoring, yet it continues to be widely used. Central fetal monitoring systems are becoming more commonplace, again without evidence of benefit. Given the design of central monitoring systems they also provide a means for surveillance of maternity clinicians as they work with birthing women.
This Doctoral research used Institutional Ethnography to critically examine the textual environment in maternity care. The findings identified the dominance of patriarchal obstetric knowledge paradigms and provided specific examples of how birthing women were considered to be risky and largely irrelevant to decision-making, the fetus was portrayed as precious and constantly at risk, and midwives were considered to be poorly informed and in need of supervision.
The frequent use of intrapartum CTG monitoring in a central monitoring system, and the intrusive behaviour of senior staff in response to perceived CTG abnormalities became logical given these assumptions. Diverting midwives’ attention away from the birthing woman to attend to the CTG monitoring system had the potential to undermine the safe provision of maternity care.
Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2020, Sept). Intrapartum cardiotocograph monitoring and perinatal outcomes for women at risk: Literature review. Women and Birth, 33(5), 411-418.
Study 2 – Tools for scaling up Midwifery Continuity of Care
Policy makers, funders, health service managers, the midwifery profession, and maternity service users need tools to model the cost-benefit impact of midwifery continuity of care to enable the case for service re-design to be effective.
We have developed a Midwifery Model Estimator to help address this need. The Estimator is a custom-built interactive business-costing tool to enable scale-up of midwifery continuity of care models for use with health services in Australia.
It provides an analysis of the cost benefit achieved relative to the proportion of women provided with midwifery continuity of care. Local data is used to model potential cost savings for the health service using different scenarios.
Study 3 – Mapping access to Midwifery Continuity of Care for vulnerable mothers and babies
This study investigates using spatial mapping to develop a population health tool to measure access, outcomes and the impact of midwifery continuity of care for vulnerable and disadvantaged groups of mothers and babies compared with other maternity models.
Women from culturally and linguistically diverse backgrounds, Indigenous women, young women, women living in poverty, and women who reside in rural and remote locations are the focus of this study.
Study 4 – Health care accreditation and maternity services reform
Australia has a complex public and private maternity health system that provides care for childbearing women, their babies and families. We also have a well-established national health care accreditation system that is government funded, legislated, and mandated, with government action for unmet standards. Hospital accreditation is the main national safety and quality system in Australia.
However, there is a disconnect between the health care accreditation and the implementation of widespread access to continuity of midwifery care.
This program of work commenced with a scoping review of the literature investigating the issues related to hospital accreditation, in particular in the Australian healthcare system, and as it relates to driving health service re-organisation towards continuity of midwifery care. Next projects are being planned and we are seeking partners to progress this work.
Gamble, J., Browne, J & Creedy, DK. (2020). Hospital accreditation: Driving best outcomes through continuity of midwifery care? A scoping review. Women and Birth, In press.
Study 5 – Obstetricians and trauma
Trauma during childbirth, such as maternal death or severe injury to a baby, impacts not only the family but maternity staff, and may contribute to a range of psychological responses, including post-traumatic stress (PTSD). Furthermore, for some medical practitioners, subsequent trauma may include stress related to being reported to the medical board. Trauma exposure and PTSD has consequences for the mental health of the individual (including possible suicide) or leaving the workforce. Doctors with burnout, or mental health conditions including PTSD, may be less able to provide appropriate patient care. Little is known about the impact of birth trauma on the mental health of obstetricians in Australia and New Zealand. Our recent feasibility study found high levels of exposure to some type of birth trauma, and presence of current symptoms of traumatic stress. Over 40 percent reported significant post-traumatic growth. Thematic analysis revealed perceptions that ‘obstetricians experience substantial trauma’, a ‘culture of blame in obstetrics’, and only ‘some workplaces were supportive and safe’.
Publications: Walker, Gamble, Creedy, Ellwood. (2019). Impact of traumatic birth on Australian obstetricians: A pilot feasibility study. Australian and New Zealand Journal of Obstetrics and Gynaecology, 60(4), 555-560. https://doi.org/10.1111/ajo.13107
Study 6 – Birth places and spaces in Australia: An exploration of the motivations and experiences of women using unlicensed birth houses
While there are few unlicensed birth houses currently operating in Australia, out-of-hospital birth continues to remain an important aspect of maternity services for some women. Currently there is a scarcity of information on birth houses and these models are in the minority. This qualitative study explores women’s experiences and motivations for choosing maternity care through unregulated birth houses to gain greater understanding for the role these birth places and spaces have in contemporary maternity services in Australia.
Study 7 – Examining facilitators and barriers to access and use of publicly funded homebirth services in Australia
Access to integrated primary health maternity services for birth at home show marked variation in Australia. There is limited knowledge of specific factors that influence demand and uptake of these services in the public sector. This study examines childbearing women’s views of the access and entry requirements to publicly funded homebirth programs and services in Australian states and territories. It focuses on understanding the facilitators and barriers to access, uptake and expansion of homebirth services from women who use or seek to use these programs.
Study 8 – Midwives conceptualisation of intrapartum risk
Midwifery care is increasingly viewed as an inherently risky area. Organisational risk management and clinical governance has a significant impact on contemporary midwifery practice. Intrapartum risk amplification is often managed by inordinate surveillance and intervention. However, increasing the focus on risk management does not necessarily facilitate the safety of the woman and her baby and may introduce iatrogenic risk.
This doctoral research has utilised phenomenography to elicit the critical variation in the qualitatively different ways midwives conceptualise intrapartum risk. The findings identified that midwives conceptualise risk as the industrial nature of maternity care and that they are navigating a dichotomy of care, trying to facilitate physiology while working in a biomedical context. This is evidenced by increasing surveillance, technology and intervention which is used to mitigate litigation and scrutiny from the trans-disciplinary milieu. The birthing woman herself is understood as a risk due to her co-morbidities or by the relationship between the woman and the midwife. Cultural risk was also a significant conceptualisation, with midwives understanding that current birthing policies relating to First Peoples women posed a significant risk.
Study 9 – Women’s experiences of negotiating and using water immersion/birth to achieve a vaginal birth after caesarean section
For women who have had a previous caesarean section keeping subsequent labours normal and free of intervention are key factors that increase the likelihood of a vaginal birth. Water immersion during labour offers potential benefits for women wanting to have a vaginal birth after caesarean (VBAC), however, its use in this cohort of women remains contentious.
Using Grounded Theory methodology this study examines women’s experiences of negotiating and/or using water immersion for their VBAC. Water was perceived by the women as a valuable tool in facilitating a natural, normal labour and birth.
The professional discourse around the use of water immersion during labour and birth, for women with a history of a previous caesarean section, remains contested. The rhetoric of risk was commonly used to control and regulate women’s choices and bodies.