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COVID-19 related maternity restrictions – more harm than good?

COVID-19 maternity care restrictions

During the global COVID-19 pandemic, maternity care guidelines have been produced rapidly and largely without evidence (Pavlidis et al., 2021). For example, US labour and birth guidelines encouraged providers to use artificial rupture of membranes; use higher doses of oxytocin to shorten length of labour; offer early epidurals; and lower the threshold for caesarean section (Stephens et al., 2020). Across the globe, women have experienced significant restrictions including prohibition of a birth companion in labour, limits around breastfeeding, and reduction in contact between mother and baby (Topalidou et al., 2020). While pregnant women commonly feel fear, stress, or concern about loss of agency during childbirth – COVID-19 has amplified these experiences by adding unknown factors about labour support and medical interventions (Almeida et al., 2020). Fears about restrictions include having to choose between a partner and a doula for labour support, or not having a labour support person at all, and fear of being separated from their baby after birth (Groschow & Floyd, 2021).

In the US, Gutschow & Davis-Floyd (2021) report recent lifting of non-evidence-based restrictions in terms of labour support, immediate skin-to-skin contact, breastfeeding and rooming-in. In Australia, however, there is community concern about increased maternity care restrictions on presence of partners at birth and on the postnatal ward, as reported by the ABC and Guardian. Researchers worldwide have raised concerns about the potential for restrictions to have long-term negative clinical and psychosocial consequences for mothers, families, and babies (Topalidou et al., 2020).

Women’s right to clinically and psychologically safe care

An article was recently published by a team who work across Europe “to ensure women’s rights to give birth in a clinically and psychologically safe environment including during the current COVID-19 pandemic” (Lalor et al., 2021). The commentary includes findings from a two-day virtual meeting of the network that included 88 clinicians and researchers from a variety of disciplines (e.g., midwifery, obstetrics, nursing, psychology) alongside lay advocacy groups from altogether 32 participating countries (Lalor et al., 2021). Information about variations in maternity care and COVID-19 related restrictions were discussed and summarised (Lalor et al., 2021).

Maternity care restrictions inconsistent and without evidence-base

The application of guidelines and restrictions was highly inconsistent between European countries (Lalor et al., 2021). Furthermore, local application of non-evidence-based restrictions significantly deviated from recommendations from the World Health Organization and professional bodies (Lalor et al., 2021). Similar international inconsistencies have been reported in intrapartum care practices outside Europe – including Australia and the United States. For example, use of nitrous oxide and water immersion during labour, birth companions, delayed cord clamping, and isolation of the newborn after birth (Pavlidis et al., 2020).

Lalor et al. (2021) raise concerns that women are being exposed to an environment where traumatic birth experiences are more likely – and where the continued implementation of harmful practices constitute a human rights violation (Lalor et al., 2021). The authors highlight that maternity care providers may be following guidelines that contradict with evidence, professional recommendations and/or deeply held values around woman-centred care – which in turn affects staff morale and productivity (Lalor et al., 2021). Indeed, a survey of key stakeholders in Australian maternity care reported that midwives and midwifery students are largely dissatisfied with restrictions that limit the quality of care they can provide (Bradfield et al., 2021).

Recommendations for maternity services and policymakers

Renfrew et al. (2020) provide key principles for services to sustain quality care during the pandemic. These include continuing to provide “evidence-informed, equitable, safe, respectful, and compassionate care for the physical and mental health of all women and newborn infants, wherever and whenever care takes place” (Renfrew et al., 2020). More specifically they recommend maintaining community-based continuity of care models, ensuring access to chosen birth support, facilitating mother-baby contact at birth, and promoting breastfeeding (Renfrew et al., 2020).

Any proposed change to maternity care practice must be considered within a quality framework, based on evidence, and evaluated for unintended effects (Lalor et al., 2021). Furthermore, women, families and staff should co-design proposed changes (Renfrew et al., 2020). Policies in response to COVID-19 have not been sensitive to maternal health – this could be addressed through the inclusion of maternal health experts in emergency planning – as well as rapid monitoring of barriers to maternity care (Takemoto et al., 2021).

Highlighted research

Lalor, J., Ayers, S., Celleja, J., Downe, S., Gouni, O., Hartmann, K., Nieuwenhuijze, M., Oosterman, M. Turner, J. D. (accepted in press, 2021). Balancing restrictions and access to maternity care for women and birthing partners during the COVID-19 pandemic: the psychosocial impact of suboptimal care. BJOG https://doi.org/10.1111/1471-0528.16844

References

Almeida M, Shrestha A. D., Stojanac B., Miller L J. (2020). The impact of the pandemic of women’s mental health. Archives Women’s Mental Health 23 (7), 741-748.  https://doi.org/10.1007/s00737-020-01092-2

Bradfield, Z., Wynter, K., Hauck, Y., Vasilevski, V., Kuliukas, L., Wilson, A. N., Szabo, R. A., Homer, C., & Sweet, L. (2021). Experiences of receiving and providing maternity care during the COVID-19 pandemic in Australia: A five-cohort cross-sectional comparison. PloS one16(3), e0248488. https://doi.org/10.1371/journal.pone.0248488

Gutschow, K., & Davis-Floyd, R. (2021). The Impacts of COVID-19 on US Maternity Care Practices: A Followup Study. Frontiers in Sociology6, 655401. https://doi.org/10.3389/fsoc.2021.655401

Pavlidis, P., Eddy, K., Phung, K., Farrington, E., Connolly, M., Lopes, R., Wilson, A.N., Homer, C.S.E., Vogel, P. (2020). Clinical guidelines for caring for women with COVID-19 during pregnancy, childbirth, and the immediate postpartum period. Women and Birth. https://doi.org/10.1016/j.wombi.2020.10.015

Renfrew, M. J., Cheyne, H., Craig, J., Duff, E., Dykes, F., Hunter, B., Lavender, T., Page, L., Ross-Davie, M., Spiby, H., & Downe, S. (2020). Sustaining quality midwifery care in a pandemic and beyond. Midwifery88, 102759. https://doi.org/10.1016/j.midw.2020.102759

Stephens A. J., Barton J. R., Bentum N.-A. A., Blackwell S. C., Sibai B. M. (2020). General Guidelines in the Management of an Obstetrical Patient on the Labor and Delivery Unit during the COVID-19 Pandemic. American Journal of Perinatolology, 37, 08, 829–836.

Topalidou, A., Thomson, G., Downe, S. (2020). COVID-19 and maternal and infant health: Are we getting the balance right? A rapid scoping review. The Practising Midwife, 23, 36- 45.

 

“Caesareans are just another way of giving birth” – right?

Caesarean section (CS) is common in high income-countries. In Australia, 35% of women give birth by caesarean, while 85% of women with a previous CS will have a repeat CS (AIHW, 2020a). However, there is increasing media interest in the concept of ‘caesarean shaming’ or ‘caesarean stigma’. Although shame is an emotion of self-blame (Heshmat, 2015), a recent media article has suggested that talking about risks of CS and benefits of normal birth, causes women who have experienced or are planning CS, to feel shame (Begg, 2021) https://www.mamamia.com.au/c-section-shaming-stories/. However, caesarean shaming is not born out in the literature – and focus on it obfuscates the issues.

Research on caesarean shaming or stigma

A quick literature search finds just two articles on CS shaming or stigma  – one is a research paper. A UK study presents results from 75 semi-structured interviews with women on a postnatal ward following a planned or unplanned CS (Tully & Ball, 2013). While some women felt stigma that they had “copped out of normal birth”; none of the women referred to feeling shamed by their decision or experience (Tully & Ball, 2013). The recent media article quotes 30 Australian women who uniformly believed their CS was lifesaving (Begg, 2021). Importantly, this echoes the UK interview results –every woman considered that her CS had been justified and necessary. Women commonly perceived it was their only option and lifesaving (Tully & Ball, 2013).

Caesareans can be life-saving but…this is epidemic

Caesarean section rates above 15% do not reduce maternal or neonatal mortality rates (Gibbons et al., 2010). Indeed, in high-income countries maternal death is exceedingly rare – 5.5 per 100,000  women who give birth in Australia will die (AIHW, 2020b). Maternity health professionals (WHO, 2018) and maternity consumer organisations (MCA, 2021) are increasingly concerned that CS is being performed without a medical or obstetric indication. Subsequently, we are experiencing a “caesarean epidemic” in high-income countries (Visser et al. 2018) – this is the story that needs to be picked up by the media.

Unnecessary caesarean creates harm without benefit

When a CS occurs without benefit, it creates unnecessary risks for mother and baby (Wise, 2018) . However, this jars with the commonly held view that CS is safer than vaginal birth because it is more “controlled” (Coates et al, 2021b).

Women who have a CS are at increased risk of birth trauma, uterine rupture, death, and future pregnancy complications including miscarriage, ectopic pregnancy, preterm birth, and stillbirth (Sandall et al., 2018). Babies born via CS have higher rates of nursery admission and lower chance of sustained breastfeeding with negative health consequences (Hobbs et al., 2016). While evidence about long-term risks for CS born children continues to emerge, they appear to include allergies and asthma; diabetes, gastroenteritis, obesity, autism, and attention deficit/hyperactivity disorder (Sandall et al., 2018; Słabuszewska-Jóźwiak et al., 2020; Zhang et al., 2019).

Early term caesarean carries additional risks

The recent Australian Commission for Safety and Quality in Healthcare report showed that 50% of CS performed before 39 weeks gestation were done without a medical indication (ACSQH, 2021). Worryingly, early planned birth (<39 weeks) increases risks for babies of breathing difficulties, admission to neonatal nursery (ASQH, 2021), and in rare instances neonatal death (Prediger et al., 2020). In addition, the long-term risks of early planned birth are learning difficulties and attention deficit hyperactivity disorder (ACSQH, 2021).

How do women make informed decisions about caesarean

The Federation of International Gynecologists and Obstetricians have released a statement that women must be “properly informed” of the risks prior to consenting for CS (Visser et al., 2018). Coates et al. (2021a) survey of Australian women’s decision-making around planned CS reported that 90% perceived they had adequate information that they understood, including risks and benefits of CS. However, 15% felt pressured or uncertain about their decision, a figure reflected in the wider literature (Coates et al., 2021a). Further research on women’s decision-making about planned birth (either induction or CS) indicates that approximately:

  • 4 in 10 women were not provided with written information before deciding
  • 1 in 5 women felt they “didn’t really have a choice” about induction or CS (Coates et al., 2021b).

What can maternity services do

Facilitating informed decision-making is part of addressing alarming rates of CS. Likewise, it may be necessary to focus on changing the maternity care system. For example, there are several system-wide strategies that have been demonstrated to reduce CS rates:

  • Providing women with continuity of midwifery care (Callander et al., 2019)
  • Benchmarking, auditing and publishing CS rates in health services (Chen et al., 2018; Visser et al., 2018)
  • Funding models that mean fees for vaginal birth and CS are the same (Visser et al., 2018)
  • Implementation of guidelines, combined with mandatory second obstetric opinion about indication for CS, and physician education (Chen et al., 2018).

Additionally, it may be useful for clinicians to reflect on how they debrief with women following a CS, especially in relation to a possible future pregnancy. For example, considering how language may be interpreted (i.e., my baby almost died) and resisting the impulse to reassure women their CS was warranted if the clinical picture and evidence suggests it was not, is important (Niemczyk, 2014).

References

Australian Institute of Health and Welfare. (2020a). Australia’s mothers and babies 2018—in brief. Canberra: AIHW.

Australian Institute of Health and Welfare. (2020b). Maternal deaths in Australia. Retrieved from https://www.aihw.gov.au/reports/mothers-babies/maternal-deaths-in-australia

Australian Commission on Safety and Quality in Healthcare. (2021).
The Fourth Australian Atlas on Healthcare Variation. Retrieved from: https://www.safetyandquality.gov.au/our-work/healthcare-variation/fourth-atlas-2021/early-planned-births

Begg, C. (2021). “I was told I had taken the easy way out.” We need to talk about C-section shaming. Mamamia. https://www.mamamia.com.au/c-section-shaming-stories/

Callander, E., Creedy, D.K., Gamble, J., Fox, H., Toohill, J., Sneddon, A., & Ellwood D. (2019). Reducing caesarean section: An economic evaluation of routine induction of labour at 39 weeks gestation in low-risk nulliparous women. Paediatric and Perinatal Epidemiology, 34(1), 3-11.

Chen I, Opiyo N, Tavender E, et al. (2018). Non-clinical interventions for reducing unnecessary caesarean section. The Cochrane Database of Systematic Reviews, 9(9): Cd005528.

Coates, D., Donnolley, N., Thirukumar, P., Lainchbury, A., Spear, V., & Henry, A. (2021a). Women’s experiences of decision-making and beliefs in relation to planned caesarean section: A survey study. The Australian & New Zealand Journal of Obstetrics & Gynaecology61(1), 106–115. https://doi.org/10.1111/ajo.13255

Coates, D., Donnolley, N., Foureur, M., Thirukumar, P., & Henry, A. (2021b). Factors associated with women’s birth beliefs and experiences of decision-making in the context of planned birth: A survey study. Midwifery96, 102944. https://doi.org/10.1016/j.midw.2021.102944

Gibbons L, Belizán JM, Lauer JA, et al. (2010). The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: overuse as a barrier to universal coverage. World Health Rep, 30, 1–31.

Heshmat, S. (2015). Five factors that make you feel shame. Psychology Today. https://www.psychologytoday.com/us/blog/science-choice/201510/5-factors-make-you-feel-shame

Hobbs, A.J., Mannion, C.A., McDonald, S.W., Brockway, M., Tough, S.C. (2016). The impact of caesarean section on breastfeeding initiation, duration and difficulties in the first four months postpartum. BMC Pregnancy and Childbirth, 16, 90.

Independent Hospital Pricing Authority. (2020). National Hospital Cost Data Collection, Round 22 (2017-18). Sydney: IHPA.

Maternity Choices Australia. (2021). 2021 Federal Election MP/Senator brief endorsed by 15 community organisations. Retrieved from https://www.maternitychoices.org/advocacy

Niemczyk, N. A. (2014). Most women think their cesarean birth was necessary. Journal of Midwifery and Women’s Health, 59, 363-364.

Prediger, B., Mathes, T., Polus, S., Glatt, A., Bühn, S., Schiermeier, S., Neugebauer, E., & Pieper, D. (2020). A systematic review and time-response meta-analysis of the optimal timing of elective caesarean sections for best maternal and neonatal health outcomes. BMC Pregnancy and Childbirth20(1), 395. https://doi.org/10.1186/s12884-020-03036-1

Sandall J, Tribe RM, Avery L, et al. (2018). Short-term and long-term effects of caesarean section on the health of women and children. The Lancet, 392(10155),1349-57.

Słabuszewska-Jóźwiak, A., Szymański, J. K., Ciebiera, M., Sarecka-Hujar, B., & Jakiel, G. (2020). Pediatrics consequences of caesarean section-A systematic review and meta-analysis. International Journal of Environmental Research and Public Health17(21), 8031. https://doi.org/10.3390/ijerph17218031

Tully, K. P., & Ball, H. L. (2013). Misrecognition of need: women’s experiences of and explanations for undergoing cesarean delivery. Social Science & Medicine, 85(1982), 103–111. https://doi.org/10.1016/j.socscimed.2013.02.039

Visser, G.H.A, Ayres-de-Campos, D., Barnea, E.R, et al. (2018). FIGO position paper: how to stop the caesarean section epidemic. The Lancet, 392(10155), 1286-1287.

Wise, J. (2018). Alarming global rise in caesarean births, figure show. British Medical Journal, 363, 4319.

World Health Organization. (2018). WHO recommendations non-clinical interventions to reduce unnecessary caesarean sections. Geneva: WHO.

Zhang T, Sidorchuk A, Sevilla-Cermeño L, et al. (2019). Association of cesarean delivery with risk of neurodevelopmental and psychiatric disorders in the offspring. JAMA Network Open, 2(8), e1910236.

 

The transformative power of birth

Induction of labour, epidural analgesia, and caesarean section are now common themes in many women’s birth stories. Women are often fearful of childbirth which may drive them to seek out medical intervention without a medical reason (Nilsson et al., 2018). Indeed, fragmented hospital maternity care supports the view that pregnancy and birth are inherently dangerous and require management and control. From this perspective, labour pain is viewed as needing ‘relief’ and the use of epidural analgesia is seen as normal practice (Newnham, McKellar, & Pincombe, 2016). The community generally lack knowledge about normal birth and in particular, the benefits of physiological birth (Wong, He, Shorey, & Koh, 2017). However, having a vaginal birth with minimal interference has considerable benefits for women and their babies in both the short and long term.

Birth is a process best supported by a known and trusted midwife

Birth is a normal and deeply significant psychological and social event in a woman’s life – and in most instances does not require medical rescue or relief. Further, there is considerable evidence that birth is best supported by a known midwife who provides reassurance, nurturing and comfort (Walsh, 2006), so that a woman can work with pain rather than resist it (Leap, Sandall, Buckland, & Huber, 2010), and feel safe enough to ‘let go’ (Anderson, 2000). When women are supported in this way, birth has the potential to be positively transformative, producing a sense of inner strength, triumph, and bliss. These transformative experiences have a lasting impact on the woman’s sense of self (Schwartz et al 2015), confidence as a new mother (Fenwick et al 2015), and relationship with her newborn (Toohill et al 2014).

New theory explains the positive potential of birth-giving

While the subject of birth trauma is gaining traction, women’s potential to positively transform through birth is not well understood. New research has addressed this gap and developed new language that can facilitate women’s conversations about their experiences. PhD candidate Ella Kurz applied feminist theory to childbirth to develop a theory that explains the transformative power of giving birth (Kurz, Davis & Browne, 2021).

The new theory, Parturescence, describes the process of women ‘becoming’ through childbirth (Kurz et al., 2021). Positive transformation results in better psycho-social well-being after birth. Whereas negative transformation includes birth trauma and psychological injury following birth. Parturescence theory refers to lines of descent (activities that bring predictability and control in birth) and lines of ascent (activities which open new ways of thinking and being). Importantly, the challenging and destabilising parts of labour and birth – and how these are mediated by maternity care – are key to women’s positive or negative transformation (Kurz et al., 2021). Midwife-woman interactions can facilitate negative or positive transformation through birth (Kurz et al., 2021). Midwives need to have the motivation and capacity to support women to feel safe, loved, relaxed and unafraid during birth – but not all midwives behave this way (Allen, Kildea, Hartz, Tracy, & Tracy, 2017). Recent research has demonstrated the importance of midwives’ social and emotional competence to establish and maintain positive relationships (Hastie & Barclay, 2021).

What does this mean for women and maternity services?

Birth has intrinsic value for women and their babies – and this should be reflected in how maternity care is organised and provided. Women and the wider community should know that women benefit from the continuous supportive presence of a known and trusted midwife who can hold the space while they transform triumphant into motherhood. Importantly, when women are treated with respect and compassion, regardless of mode of birth, there is potential for positive transformation.

Highlighted research

Kurz, E., Davis, D., & Browne, J. (2021). Parturescence: A theorisation of women’s transformation through childbirth. Women and Birth. https://doi.org/10.1016/j.wombi.2021.03.009

References

Allen, J., Kildea, S., Hartz, D. L., Tracy, M., & Tracy, S. (2017). The motivation and capacity to go ‘above and beyond’: Qualitative analysis of free-text survey responses in the M@NGO randomised controlled trial of caseload midwifery. Midwifery, 50, 148-156. https://doi.org/10.1016/j.midw.2017.03.012

Anderson, T. (2000). Feeling safe enough to let go: the relationship between a woman and her midwife during the second stage of labour. In M. Kirkham (Ed.), The Midwife–Mother Relationship. Macmillan Press.

Fenwick J, Toohill J, Gamble J, Creedy DK, Buist A, Turkstra E, Sneddon A, Scuffham PA, & Ryding EL. (2015). Effects of a midwife psycho-education intervention to reduce childbirth fear on women’s birth outcomes and psychological well-being. BMC Pregnancy & Childbirth, 15, 284. https://doi.org/10.1186/s12884-015-0721-y

Hastie, C. R., & Barclay, L. (2021). Early career midwives’ perception of their teamwork skills following a specifically designed, whole-of-degree educational strategy utilising groupwork assessments. Midwifery. https://doi.org/10.1016/j.midw.2021.102997

Kurz, E., Davis, D., & Browne, J. (2021). Parturescence: A theorisation of women’s transformation through childbirth. Women and Birth. https://doi.org/10.1016/j.wombi.2021.03.009

Leap, N., Sandall, J., Buckland, S., & Huber, U. (2010). Journey to Confidence: Women’s Experiences of Pain in Labour and Relational Continuity of Care. Journal of Midwifery & Women’s Health, 55(3), 234-242. https://doi.org/10.1016/j.jmwh.2010.02.001

Newnham E., McKellar L., & Pincombe, J. (2016). A critical literature review of epidural analgesia. Evid Based Midwifery, 14(1), 22-28.

Nilsson, C., Hessman, E., Sjöblom, H., Dencker, A., Jangsten, E., Mollberg, M., . . . Begley, C. (2018). Definitions, measurements and prevalence of fear of childbirth: a systematic review. BMC Pregnancy Childbirth, 18(1), 28. https://doi.org/10.1186/s12884-018-1659-7

Schwartz L, Toohill J, Creedy DK, Baird K, Gamble G & Fenwick J. (2015) Factors associated with childbirth self-efficacy in childbearing women. BMC Pregnancy and Childbirth, 15:29.

Wong, C. Y. W., He, H. G., Shorey, S., & Koh, S. S. L. (2017). An integrative literature review on midwives’ perceptions on the facilitators and barriers of physiological birth. International Journal of Nursing Practice, 23(6). https://doi.org/10.1111/ijn.12602

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

 

Psychological trauma regarding birth and helpful responses – Podcast

This week is Birth Trauma Awareness week. There is increasing recognition that a significant proportion of women describe some aspect of their birth as traumatic. This week provides an opportunity to focus on what can be done to prevent, and respond appropriately to, women’s experiences of their births as a form of psychological trauma.

Professor Jenny Gamble, Director of Transforming Maternity Care, recorded a podcast with Annalee Atia from Pregnancy Birth and Beyond earlier this week. In the podcast Professor Gamble explained that women may experience their birth as traumatic if they feel that there was threat to their life or safety or their baby’s (or babies’) life or safety. About 30% of Australian women report that their birth was traumatic and have some trauma symptoms at 4-6 weeks after birth.

All women should be asked about their birth experience and provided with sufficient time and empathy to be able to talk about it. The process of care is key to whether women experienced birth as traumatic. Technically poor care, failures of communication, care with coercion and without consent, and excluding the woman from decision making contribute to experiencing the birth as traumatic.

Human intent in the harm or threat experienced is significant in the development of traumatic stress and PTSD. If women feel their trust was betrayed or that they received treatment with callous disregard they are more likely to experience birth as traumatic.

The podcast explains helpful early responses for maternity care providers and others. For some women, following the trauma and the struggle to cope and work through the impact of their birth experience, report positive change and growth. These women are beacons of hope and often an empathetic ‘home’ for others experiencing adversity.

You can listen to the Podcast here. Other events held during Birth Trauma Awareness week are hosted on the Facebook page of the Maternal Mental Health Matters Australia 2020 group, along with helpful resources for people who have been affected by birth trauma.