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What makes maternity care “worth it”?

Childbirth is the most common reason for hospitalisation and the most expensive. Many high-income countries have witnessed escalating obstetric intervention rates (“too much, too soon”) with either no improvement or worsening health outcomes for women and babies (Miller et al., 2016). Overuse, or misuse, of medical intervention is wasteful of resources – and perhaps more importantly, it harms mothers and babies (Miller et al., 2016) – with potential life course consequences (Peters et al., 2018).

Quality care maternity care has been referred to “right care” (Kennedy et al., 2018). Right care is woman-centred and individualised, informed by evidence, cost-effective, includes consideration of benefits and harms, strengthens equity and is available across the continuum (World Health Organization, 2016).

Value-based maternity care

Value-based healthcare means care that is not only safe and effective, but “worth it” for the people providing care, receiving care, and paying for care (Sudhof & Shah, 2019). Value, however, is hard to measure. When hospitals and clinicians that provide maternity care are reimbursed for the quantity of services, rather than the quality of services, there is no incentive to provide right care (Sudhof & Shah, 2019). The authors describe some of the barriers to providing high-value maternity care – time pressure, fear of malpractice, and misaligned financial incentives (Sudhof & Shah, 2019).

Sudhof & Shah (2019) recommend five strategies to deliver high-value maternity care:

  1. When treatments are equivalent, choose based on price. For example, birth centre care for women at low risk of complications.
  2. Critically evaluate and individualise emerging technologies. For example, consider the cost, risk, and benefit of specific screening tests rather than offering them to all pregnant women.
  3. Prioritise team-based approaches to care. For example, provide collaborative obstetric and midwifery care, and access to professional labour support.
  4. Integrate contraception and pregnancy counselling. For example, provide access to immediate postpartum long-acting reversible contraception.
  5. Expand ways of engaging women in maternity care. For example, consider home visits for women that are otherwise hard to reach or follow up.

Value-based performance programs

Many countries have implemented and evaluated value-based performance (VBP) programs to financially reward quality of care (Chee et al., 2017). For example, the US Hospital VBP program takes 2% of the participating hospitals’ diagnosis-related payments for the financial year to redistribute based on each hospital’s quality performance (U.S. Centers for Medicare & Medicaid Services, 2021). Quality performance is measured in four areas: 1) clinical outcomes; 2) patient-reported experience measure; 3) safety and 4) efficiency. A systematic review of VBP programs reports they are marginally effective in some settings, but some results are mixed, and some positive changes are not sustained (Chee et al., 2017). The review authors identified several opportunities to strengthen VBP programs. For example, getting better at measuring what ‘quality’ is and increasing the size and design of financial incentives (Chee et al., 2017).

Currently, in the US Hospital VBP program, women who have given birth in hospital are combined with all other hospital patients. Indeed, there is no specific VBP programs for maternity and/or obstetric care in any country. In addition, the patient-reported outcome and experience measures used in VBP programs are not specific to pregnancy and childbirth (Childbirth Connections, 2016).

Patient reported outcomes and experiences 

Kennedy et al. (2018) recommend research to determine which measures can be used to effectively see quantifiable improvements in clinical outcomes and women’s experiences during pregnancy and childbirth. A Patient Reported Outcome Measure (PROM) is used to get healthcare users views of “their symptoms, their functional status, and their health-related quality of life” (Black, 2013). Whereas a Patient Reported Experience Measure (PREM) refers to the person’s experiences of the healthcare services they received (Chen et al., 2021); specifically, what happened during their care encounter and how it happened (Bull et al., 2019). The International Consortium for Health Outcomes Measurement have developed a Pregnancy and Childbirth outcome set of 24 measures that are internationally appropriate and represent what matters to women and families (Nijagal et al., 2018). While research using these measures has been limited, routine collection would be valuable for health services (Chen et al., 2021).

Conclusion

Once the ICHOM pregnancy and childbirth outcome set has been validated across international settings, it could be used to benchmark and incentivise the improvement of maternity care (Nijagal et al., 2018). Potentially, this could be incorporated intoa  maternity-specific VBP program. Reducing unnecessary interventions and improving the quality of care during childbirth is not only critical to the outcomes and experiences of childbearing women and newborns – it would save the taxpayer money (Childbirth Connections, 2016).

Highlighted article

Sudhof, L. & Shah, N.T. (2019). In pursuit of value-based maternity care. Obstetrics & Gynecolology, 133, 541–551. https://doi.10.1097/AOG.0000000000003113

References

Black N. (2013). Patient reported outcome measures could help transform healthcare. British Medical Journal, 346(167). https://doi.org/10.1136/bmj.f167

Bull C, Byrnes J, Hettiarachchi R, Downes M. (2019). A systematic review of the validity and reliability of patient-reported experience measures. Health Services Research, 54(5), 1023-1035.

Chee, T. T., Ryan, A. M., Wasfy, J. H., & Borden, W. B. (2016). Current state of value-based purchasing programs. Circulation133(22), 2197–2205. https://doi.org/10.1161/CIRCULATIONAHA.115.010268

Chen, A., Väyrynen, K., Leskelä, R. L., Heinonen, S., Lillrank, P., Tekay, A., & Torkki, P. (2021). A qualitative study on professionals’ attitudes and views towards the introduction of patient reported measures into public maternity care pathway. BMC Health Services Research21(1), 645. https://doi.org/10.1186/s12913-021-06658-z

Childbirth Connections. (2016). The Quality Care for Moms and Babies Act: Improving Maternity Care for Women and Families. National Partnership for Women and Families.

Dickinson, F., McCauley, M., Smith, H., & van den Broek, N. (2019). Patient reported outcome measures for use in pregnancy and childbirth: a systematic review. BMC Pregnancy and Childbirth, 19(1).

Kennedy, HP, Cheyney, M, Dahlen, HG, et al. (2018). Asking different questions: A call to action for research to improve the quality of care for every woman, every child. Birth: Issues in Perinatal Care, 45, 222- 231. https://doi.org/10.1111/birt.12361

Miller, S., et al. (2016). Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. The Lancet, 388(10056), 2176 – 2192.

Nijagal, M. A., Wissig, S., Stowell, C., Olson, E., Amer-Wahlin, I., Bonsel, G., Brooks, A., Coleman, M., Devi Karalasingam, S., Duffy, J., Flanagan, T., Gebhardt, S., Greene, M. E., Groenendaal, F., R Jeganathan, J. R., Kowaliw, T., Lamain-de-Ruiter, M., Main, E., Owens, M., Petersen, R., … Franx, A. (2018). Standardized outcome measures for pregnancy and childbirth, an ICHOM proposal. BMC Health Services Research18(1), 953. https://doi.org/10.1186/s12913-018-3732-3

Peters LL, Thornton C, de Jonge A, et al. (2018). The effect of medical and operative birth interventions on child health outcomes in the first 28 days and up to 5 years of age: a linked data populationbased cohort study. Birth: Issues in Perinatal Care, 1‐11.

Symon, A., Downe, S., Finlayson, K. W., Knapp, R., & Diggle, P. (2015). The feasibility and acceptability of using the Mother-Generated Index (MGI) as a patient reported outcome measure in a randomised controlled trial of maternity care. BMC Medical Research Methodology, 15(92).

U.S. Centers for Medicare & Medicaid Services. (2021). Hospital Value-Based Purchasing Program. Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HVBP/Hospital-Value-Based-Purchasing.

World Health Organization. (2016). WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. World Health Organization.

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.

 

Midwifery centres – the what, the how, the why

Women across the globe (in low-, middle- and high-income countries) are concerned about misuse of medical intervention, and disrespectful or abusive treatment during labour and birth (World Health Organization, 2014). For example, in Mexico where the caesarean section rate is 50%, 30% of women report they have experienced ‘obstetric violence’ (Alonso et al., 2018). Whereas the poorest women in Sub Saharan Africa usually give birth at home either unattended (56%) or with a traditional birth attendant (41%), because they lack access to a skilled birth attendant, or do not think one is needed (Montagu et al., 2011). Midwifery centres – also known as birth centres – are sought by women who want to experience safe, respectful, and satisfying birth in a facility, while avoiding unnecessary intervention (Stevens & Alonso, 2020).

What is a midwifery centre?

A Midwifery Centre is a home-like healthcare facility that is guided by a midwifery philosophy of care, centred on the woman’s experience, specialising in physiological birth, with access to basic emergency care, and fully integrated within the healthcare system (Stevens & Alonso, 2020). Midwifery centres operate all over the world in over 56 countries – see map here. While midwifery centres could be key to achieving quality maternal and newborn care, there are negative perceptions about their capacity, limited understanding of what midwives do, and lack of access globally.

Midwifery centres in high-income countries

In high-income countries (e.g., Australia, Canada, United Kingdom, United States) highest-level evidence demonstrates women who plan to birth in a midwifery centre have a higher chance of normal birth, with a lower chance of obstetric intervention, and no difference in infant mortality (Scarf et al., 2018). Approximately 3% of women in Australia give birth in a midwifery centre. A study in one Australian state determined that 34% of women having their first baby, and 12% of women having a subsequent baby, were transferred from a midwifery centre and gave birth in hospital (Scarf et al., 2019). While there has been a near doubling of demand for midwifery centres in Australia over the past two decades, access has remained limited and birth numbers in midwifery centres have been static (Adelson et al., 2021).

Midwifery centres in low-income countries

In low- and middle- income countries, less is known about the outcomes associated with midwifery centre care. In these settings, there are challenges including lack of equipment, supplies, medication, blood, electricity and water; combined with difficulty transferring women to higher level care when needed either through lack of transport or women’s unwillingness to access hospital care (Munabi-Babigumira et al., 2017). Furthermore, midwifery centres in low- and middle- income countries tend to operate outside the healthcare system. Safe and respectful care, with seamless access to higher level services when required, is key to increasing access to skilled birth attendants in low- and middle-income countries; and therefore, addressing maternal and infant mortality in these settings.

How standards contribute to quality care

Without international standards, including a consensus definition of what a midwifery centre is (and is not), it is difficult to implement, monitor, evaluate and scale up.  Rigorously developed international standards guide funders, policy makers, managers and maternity advocates. It is important to be able to measure and compare outcomes between midwifery centres within and between countries, while accounting for variation in the population.

Development of international standards

Researchers Stevens & Alonso (2021) wanted to develop clear guidance through international standards to ensure the quality of care provided in midwifery centres. To do this, they initially gathered midwifery centre operation standards from the United States and Europe and compared these with international guidance on quality of maternal and newborn care, rights of childbearing women, and respectful maternity care (Stevens & Alonso, 2021). The research team analysed the documents to determine commonalities and to develop draft international standards. Next, international experts in low-, middle- and high-income settings provided feedback on the draft standards. The researchers then piloted 52 standards at 8 midwifery centres in 8 countries (Sierra Leone, Cambodia, Bangladesh, Mexico, Haiti, Peru, Uganda, and Trinidad) (Stevens & Alonso, 2021). Discussions with the pilot sites helped determine the final list.

Assessing how midwifery centres meet international standards

The Operational Standards for Midwifery Centers are freely available here. There are 43 process standards in three domains: Dignity, Quality, and Community-Facility (Stevens & Alonso, 2021). Each standard includes indicators which can be used to measure and assess whether, and how, the standard is met. Dignity includes 13 standards that are focussed on the woman. For example, Standard 10 Every mother is informed about the benefits of supporting physiological processes, includes indicators like policy, and woman’s health record. Quality includes 13 standards that are focussed on the maternity care providers. For example, Standard 24 At every birth, there are at least two staff currently trained for emergency management of common birth complications, can be assessed through staff education logs and birth documentation. Community-Facility includes 17 standards that are about administration. For example, Standard 31 The facility has functioning, reliable, safe, and sufficient systems for each of the following: clean water, dependable energy, facility sanitation, hand hygiene, general waste disposal, and medical waste disposal, can be assessed through availability of policies and procedures.

Primary midwifery care is the solution

Some argue that universal access to high-quality obstetric care and facility-based birth is the path to address maternal and infant mortality in low- and middle-income countries (Bohren et al., 2014). From this perspective, midwives are seen as an ‘add on’ to provide emotional support during obstetric-led birth (Austad et al., 2021). An alternative solution, that would address women’s expressed desires to birth close to home, with minimal intervention, and avoid disrespectful care, would be to rapidly scale up midwifery centres that meet international standards. Primary midwifery care should be the foundation of any maternity system. Midwives need to be supported in systems and health services to deliver care and outcomes for women and babies.

Scale-up of midwifery centres

Using the term ‘midwifery centre’ instead of ‘birth centre’ may help reorient thinking about how best to organise and provide quality maternal and newborn care. In high-income settings, a midwifery centre is not a room with an armchair and a birth pool within an obstetric-led unit. Midwifery centres are midwifery-led, woman-centred – designed to promote physiological birth and enable midwives to work to their full scope of practice. In low- and middle-income settings, a facility outside the hospital that offers birth care, but is not fully integrated to enable consultation, referral and transfer to higher level services, is also not a midwifery centre. The consensus definition and operational standards can be used in any global setting to establish, monitor and scale-up midwifery centres.

Highlighted research

Stevens, J. R., & Alonso, C. (2021). Developing operational standards for Midwifery Centers. Midwifery, 93, 102882. https://doi.org/10.1016/j.midw.2020.102882

References

Adelson, P., Fleet, J. A., McKellar, L., & Eckert, M. (2021). Two decades of Birth Centre and midwifery-led care in South Australia, 1998-2016. Women and Birth34(1), e84–e91. https://doi.org/10.1016/j.wombi.2020.05.005

Alonso, C., Storey, A. S., Fajardo, I., & Borboleta, H. S. (2021). Emergent change in a Mexican midwifery center organization amidst the COVID-19 crisis. Frontiers in Sociology6, 611321. https://doi.org/10.3389/fsoc.2021.611321

Austad, K., Juarez, M., Shryer, H. et al. (2021). Improving the experience of facility-based delivery for vulnerable women through obstetric care navigation: a qualitative evaluation. BMC Pregnancy and Childbirth, 21, 425. https://doi.org/10.1186/s12884-021-03842-1

Bohren, M.A., Hunter, E.C., Munthe-Kaas, H.M. et al. (2014). Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reproductive Health, 11, 71.

Montagu D, Yamey G, Visconti A, Harding A, Yoong J (2011) Where Do Poor Women in Developing Countries Give Birth? A Multi-Country Analysis of Demographic and Health Survey Data. PLOS ONE, 6(2): e17155. https://doi.org/10.1371/journal.pone.0017155

Munabi-Babigumira, S., Glenton, C., Lewin, S., Fretheim, A., & Nabudere, H. (2017). Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis. The Cochrane Database of Systematic Reviews11(11), CD011558. https://doi.org/10.1002/14651858.CD011558.pub2

Scarf, V. L., Viney, R., Yu, S., Foureur, M., Rossiter, C., Dahlen, H., Thornton, C., Cheah, S. L., & Homer, C. (2019). Mapping the trajectories for women and their babies from births planned at home, in a birth centre or in a hospital in New South Wales, Australia, between 2000 and 2012. BMC Pregnancy and Childbirth19(1), 513. https://doi.org/10.1186/s12884-019-2584-0

Scarf, V. L., Rossiter, C., Vedam, S., Dahlen, H. G., Ellwood, D., Forster, D., . . . Homer, C. S. E. (2018). Maternal and perinatal outcomes by planned place of birth among women with low-risk pregnancies in high-income countries: A systematic review and meta-analysis. Midwifery, 62, 240-255. https://doi.org/10.1016/j.midw.2018.03.024

Stevens, J. R., & Alonso, C. (2020). Commentary: Creating a definition for global midwifery centers. Midwifery, 85, 102684. https://doi.org/10.1016/j.midw.2020.102684

World Health Organization. (2014). Prevention and elimination of disrespect and abuse during childbirth. Retrieved from: https://www.who.int/reproductivehealth/topics/maternal_perinatal/statement-childbirth/en/

Strategies that work to increase vaginal birth rate after caesarean

Vaginal birth after caesarean around the world

VBAC is a vaginal birth after caesarean section. While planned VBAC is a safe choice for most women, rates of VBAC vary considerably. VBAC rates are high in countries like Finland, Sweden and Netherlands (approximately 50%), lower in Ireland, Scotland, Italy, Spain and Germany (approximately 30%), and lowest in countries like the US and Australia (approximately 12%) (Lundgren et al., 2020). Indeed, the rate of successful VBAC in Australia has remained stagnant over the past decade – 13.1% in 2007 to 12.1% in 2018 (Australian Institute of Health and Welfare, 2020).

Research finds that in settings where rates are low , VBAC is not considered the obvious first choice for most women (Lundgren et al., 2020). Furthermore, obstetricians tend to determine whether VBAC should be attempted in countries with low-rates rather than women themselves (Lundgren et al., 2020). In a recent US study, women described having to “fight hard” for a VBAC including navigating obstacles, finding a supportive care provider, and sometimes travelling long distances to access care (Basile Ibrahim et al. 2021). Wingert et al. (2018) conducted a systematic review of all studies that had looked at the impact of interventions (e.g., education) on planned and/or successful VBAC rates.

Strategies for maternity care providers

Education for healthcare providers about the benefits of VBAC was effective, particularly when it was provided by a respected obstetric opinion leader (Wingert et al., 2018). When doctors were required to seek a second opinion from an obstetrician – regarding first or subsequent caesarean section (CS) – the rates of planned and successful VBACs increased (Wingert et al., 2018). Furthermore, having a night float on-call system which uses doctors who were more rested, compared to doctors on a 24-hour on-call shift, increased VBAC success rates (Wingert et al., 2021). 

Strategies for pregnant and birthing women

The systematic review included several studies that assessed the usefulness of a decision aid, compared to no decision aid, for women choosing between VBAC and CS for their next birth. Every decision aid was associated with an increase in women’s knowledge and decrease in their anxiety about decision –  but none of the decision aids made a difference to planned VBAC rates (Wingert et al., 2018).

Health system strategies

Providing hospitals funding contingent on increasing VBAC rates was an effective strategy in one study (Wingert et al., 2018). Models of care – midwifery continuity of carer, midwifery antenatal continuity, and dedicated VBAC antenatal clinics – were associated with higher rates of planned and successful VBAC compared to standard care (Wingert et al., 2018).

Midwifery continuity of carer models

Women’s experiences of planned VBAC in midwifery continuity of carer models were more positive than standard care (Keedle et al., 2020). For example, women were more likely to feel in control of their decision making and feel their health care provider positively supported their decision to have a VBAC.  Furthermore, women with a known midwife were more likely to have been active in labour, labour in water, and use an upright birth position (Keedle et al., 2020).

A small randomised trial aimed to compare a midwifery continuity of carer model (antenatal, birth, postnatal), with a midwifery antenatal continuity model, on VBAC rates (Homer et al., 2021). In this study, there was no significant difference between midwifery continuity of carer or antenatal continuity for planned VBAC (67% vs 57%) or VBAC success (28% vs 33%)  (Homer et al., 2021). However, the likely reason was that both models were similar to each other (i.e. women saw a similar number of midwives antenatally and during labour and birth) (Homer et al., 2021). Therefore, a trial of midwifery continuity of carer – using a model where a genuine and trusting relationship can develop between midwife and woman – is still required (Homer et al., 2021).

Recommendations to support VBAC

Health services should increase access to models of care that include a significant role for midwives, and use evidence-based strategies that proactively encourage vaginal birth for women after previous CS (Davis et al., 2020).

Maternity care providers can facilitate women to plan a VBAC by providing information in a supportive way, viewing VBAC as the first alternative in the absence of complications, and helping women to ‘let go’ of their previous childbirth experience to prepare for their next birth (Nilsson et al., 2017). The discussion of risks and benefits for next birth after CS, should include information about recovery from surgical birth (Davis et al., 2020). During labour, midwives and obstetricians can help women achieve a VBAC by offering calm and confident support  (Nilsson et al., 2017).

A national mass media public health campaign about the benefits of VBAC has been an effective strategy in one country with low rates of planned VBAC. Women who viewed the campaign had increased self-reported knowledge, positive attitude towards VBAC and higher intention toward VBAC (Majilesi et al., 2020). A similar campaign could be considered in other countries with low rates of VBAC intention.

Highlighted research

Homer, C., Davis, D. L., Mollart, L., Turkmani, S., Smith, R. M., Bullard, M., Leiser, B., & Foureur, M. (2021). Midwifery continuity of care and vaginal birth after caesarean section: A randomised controlled trial. Women and Birth, S1871-5192(21)00089-5. Advance online publication. https://doi.org/10.1016/j.wombi.2021.05.010

References

Australian Institute of Health and Welfare. (2020). National Core Maternity Indicators 2018: summary report. Retrieved from Canberra: https://www.aihw.gov.au/reports/mothers-babies/national-core-maternity-indicators-summary-report

Basile Ibrahim, B., Knobf, M. T., Shorten, A., Vedam, S., Cheyney, M., Illuzzi, J., & Kennedy, H. P. (2021). “I had to fight for my VBAC”: A mixed methods exploration of women’s experiences of pregnancy and vaginal birth after cesarean in the United States. Birth (Berkeley, Calif.)48(2), 164–177. https://doi.org/10.1111/birt.12513

Davis, D., S Homer, C., Clack, D., Turkmani, S., & Foureur, M. (2020). Choosing vaginal birth after caesarean section: Motivating factors. Midwifery88, 102766. https://doi.org/10.1016/j.midw.2020.102766

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 Childbirth20(1), 381. https://doi.org/10.1186/s12884-020-03075-8

Lundgren, I., Morano, S., Nilsson, C., Sinclair, M., & Begley, C. (2020). Cultural perspectives on vaginal birth after previous caesarean section in countries with high and low rates – A hermeneutic study. Women Birth, 33(4), e339-e347. https://doi.org/10.1016/j.wombi.2019.07.300

Majlesi, M., Montazeri, A., Rakhshani, F., Nouri-Khashe-Heiran, E., & Akbari, N. (2020). ‘No to unnecessary caesarean sections’: Evaluation of a mass-media campaign on women’s knowledge, attitude and intention for mode of delivery. PloS One15(8), e0235688. https://doi.org/10.1371/journal.pone.0235688

Nilsson, C., van Limbeek, E., Vehvilainen-Julkunen, K., & Lundgren, I. (2017). Vaginal birth after cesarean: Views of women from countries with high VBAC rates. Qualitative Health Research27(3), 325–340. https://doi.org/10.1177/1049732315612041

Wingert, A., Johnson, C., Featherstone, R., Sebastianski, M., Hartling, L., & Douglas Wilson, R. (2018). Adjunct clinical interventions that influence vaginal birth after cesarean rates: Systematic review. BMC Pregnancy and Childbirth18(1), 452. https://doi.org/10.1186/s12884-018-2065-x

Equipping midwifery leaders to drive reform

Maternity services reform

The maternity reform agenda aims to re-orient maternity care to be primary health focussed, community-based and woman-centred.  Woman-centred care requires access to a known and trusted midwife, commonly provided through a Midwifery Group Practice (MGP). The evidence is clear that MGP is gold standard, but implementation of these models in Australia has been slow (Hewitt et al., 2021a), which has resulted in 90% of women without access (Dawson et al., 2015). Midwives in leadership roles are ideally placed to drive maternity services reform, including rollout of MGP models of care. Research has identified what makes an effective midwifery leader –  clinical experience and skill, good communication, emotional intelligence, innovation and desire to make a difference (Byrom & Downe, 2010). However, little is known about what midwifery leaders specifically need to re-orient maternity services.

Exploring midwifery leaders’ perspectives

Masters of Primary Maternity Care student, Joy Adcock, recently conducted a study under the supervision of Professors Emeritus Mary Sidebotham and Jenny Gamble. The qualitative study sought to answer the question: What do midwives in leadership positions need to be effective in contributing to the reform of maternity services in Australia? The first author interviewed 13 Australian midwifery leaders – midwifery consultants, midwifery unit managers, MGP managers, midwifery service directors, and state/national midwifery leaders. The research team analysed interview data to describe the views and perspectives of midwifery leaders.

What midwifery leaders need 

Resilience, bravery and confidence were crucial for midwifery leaders to manage resistance and barriers to implementation of MGP (Adcock et al., 2021). Midwifery leaders who demonstrated a strong motivation and commitment to implementing midwifery continuity of care, were more able to navigate set-backs and drive maternity reform (Adcock et al., 2021). This ability was underlined by a belief that MGP was ‘the answer’ to maternity care and a determination to use the evidence to improve care for mothers and babies (Adcock et al., 2021). With this foundation, effective leaders described influencing the midwifery culture of their organisation to embody woman-centred care (Adcock et al., 2021).

Participants described their need for support from their organisation and from respectful relationships with key stakeholders (Adcock et al., 2021). Indeed, trusting relationships across all organisational levels is critical for midwifery continuity of care to work (McInnes et al., 2021). To achieve positive relationships, leaders described learning to speak ‘executives’ language’, form strategic alliances with like-minded obstetricians, challenge medical views, and respond to the needs of midwives and consumers (Adcock et al., 2021). This fits with a study of  MGP managers that found that the ability to advocate for midwives and women was key to the role (Hewitt et al., 2019).

Midwifery leaders valued opportunities for professional development in the form of leadership training, mentoring and clinical supervision (Adcock et al., 2021). Indeed, previous research has emphasised the importance of leadership attributes and development opportunities for midwifery leaders (Byrom & Downe, 2010; Hewitt et al., 2018; Miskelly & Duncan, 2014).

Recommendations

Midwifery leaders need to be specifically equipped to drive maternity care reform. To facilitate midwifery leaders to reach their potential requires investment in their professional development through leadership training and mentoring programs (Adcock et al., 2021). To effectively lead the change, midwifery leaders require a strong personal commitment and confidence to push for expansion of MGP.  This commitment could be strengthened by developing a network of Australian midwifery leaders (Adcock et al., 2021) to share strategies, support and bolster resilience. Additionally, there must be a willingness and ability to develop and nurture strategic relationships.  Because midwifery is a profession separate from nursing, midwifery leaders should be included on executive leadership teams, rather than represented by nursing leaders (Adcock et al., 2021). The role of midwifery leaders is to ensure MGP is “prioritised, nurtured and embraced” (Hewitt et al., 2021b).

Highlighted research

Adcock, J. E., Sidebotham, M., & Gamble, J. (2021, 2021/04/28/). What do midwifery leaders need in order to be effective in contributing to the reform of maternity services? Women and Birth. https://doi.org/https://doi.org/10.1016/j.wombi.2021.04.008

References

Byrom, S., & Downe, S. (2010). ‘She sort of shines’: midwives’ accounts of ‘good’ midwifery and ‘good’ leadership. Midwifery, 26(1), 126-137. https://doi.org/10.1016/j.midw.2008.01.011

Dawson, K., Newton, M., Forster, D., & McLachlan, H. (2015, 2015/01/01/). Caseload midwifery in Australia: What access do women have? Women and Birth, 28, S12. https://doi.org/https://doi.org/10.1016/j.wombi.2015.07.048

Hewitt, L., Dahlen, H. G., Hartz, D. L., & Dadich, A. (2021a). Leadership and management in midwifery-led continuity of care models: A thematic and lexical analysis of a scoping review. Midwifery98, 102986. https://doi.org/10.1016/j.midw.2021.102986

Hewitt, L., Dadich, A., Hartz, D. L., & Dahlen, H. G. (2021b). Management and sustainability of midwifery group practice: Thematic and lexical analyses of midwife interviews. Women and Birth, S1871-5192(21)00081-0. Advance online publication. https://doi.org/10.1016/j.wombi.2021.05.002

Hewitt, L., Priddis, H., & Dahlen, H. G. (2018). What attributes do Australian midwifery leaders identify as essential to effectively manage a Midwifery Group Practice? Women and Birth. https://doi.org/https://doi.org/10.1016/j.wombi.2018.06.017

McInnes, R. J., Aitken-Arbuckle, A., Lake, S., Hollins Martin, C., & MacArthur, J. (2020). Implementing continuity of midwife carer – just a friendly face? A realist evaluation. BMC Health Services Research20(1), 304. https://doi.org/10.1186/s12913-020-05159-9

Health services lack incentive to be cost-effective

Maternity service funding in Australia

Most maternity care funding is allocated to State and Territory health departments who then resource hospitals and health services. The funding given to health services is ‘activity-based’ which means the more episodes of care, and the more expensive types of care provided, the more funding the health services receive (COAG, 2014). Complex care (e.g., caesarean surgery, inpatient postnatal ward stay) costs more to provide, and therefore attracts more funding under this activity-based scheme, than normal birth with early discharge.  Therefore, health services may have no incentive to provide models of care that are cost-effective – even if they deliver better outcomes and experiences for women and babies.

Cost and benefits of maternity care up to 12-months after birth

Deputy Director of Transforming Maternity Care Collaborative, Associate Professor Emily Callander, is an expert in the health economics of maternity care. She recently led a study to determine the cost and benefit (in terms of quality of life) associated with public midwifery continuity of carer (Midwifery Group Practice – MGP)(Callander et al., 2021). MGP was compared with standard care, which included all other models of public maternity care, and excluded private obstetric/midwifery care.

The study collected data from 85 women who had continuity of carer and 72 women who had standard care, including data about their infants. The women in each group were similar in terms of parity, education, and insurance status. The two key measures were ‘health-related quality of life’ and ‘cost’. Quality of life years were calculated based on participant surveys using valid tools at study entry, 36-weeks of pregnancy – and then 6 weeks, 6 months, and 12 months post-partum. Cost was assessed including costs to Medicare, hospital funders and women through out-of-pocket expenses.

Public MGP was 22% cheaper than other models of care – it delivered a cost-saving of approximately $5,000 per woman to hospital funders. The researchers explained this cost-saving was largely because of shorter inpatient hospital stays. At the same time public MGP delivered similar outcomes (quality of life up to 12 months after birth) compared to standard care. Callander et al. (2021) results build on previous evidence of the cost-saving benefit of public MGP in Australian settings.

MGP delivers cost-savings for different groups

Women with low-risk status

Toohill et als., (2012) study of low-risk women who accessed either birth centre MGP, or standard care, calculated an approximate $1,000 cost-saving per woman with MGP. Women in MGP had a lower chance of induction of labour, fewer antenatal visits, and fewer neonatal admissions to nursery – which explained the cost-saving (Toohill et al., 2012).

Women with any-risk status

The M@NGO trial demonstrated that MGP  delivered an approximate cost-saving of $500 per woman compared to standard care (Tracy et al., 2013). This cost-saving was because women allocated to MGP had one fewer antenatal visit, were more likely go into labour spontaneously, use less pharmacological analgesia, have fewer postpartum haemorrhages, and have a shorter length of postnatal stay (Tracy et al., 2013).

Women with low-risk having their first baby

The cost of maternity care for first-time, low-risk women in 3 models – public MGP, public standard care, and private obstetric care –  was cheaper in public MGP  (approximate cost-saving $1500 per woman)(Tracy et al., 2014). This cost-saving was largely explained by lower rates of induction of labour and elective caesarean section, and lower rates of instrumental/surgical birth in public MGP (Tracy et al., 2014).

Aboriginal mothers

Gao et al. (2014) conducted a study of the cost consequences of MGP for Aboriginal mothers and infants compared to standard care. While Aboriginal mothers who accessed MGP had more antenatal care, including antenatal admissions, if their babies went to special care nursery they had a shorter length of stay, compared to babies born to Aboriginal mothers in standard care  (Gao et al., 2014). The study reported an approximate cost-saving $700 per woman associated with MGP.

Return on investment in safe quality care

The evidence is clear. Investing in expansion of public MGP is a more efficient use of health resources than the status quo. In the absence of financial incentives, however, the status quo in Australia – where <20% of women have access to MGP – is likely to persist. There is precedent to show that financial incentives and disincentives impact maternity care provision. For example, providing the same ‘delivery fees’ for vaginal birth and caesarean birth in both public and private, is an effective strategy to curb the overuse of caesarean section (V isser et al., 2018).

Alternative funding models, namely bundled funding, work in other countries that have high levels of access to MGP (e.g., New Zealand). In these models, services are provided a single payment for each birth, which covers all the care provided to the woman throughout pregnancy, intrapartum, and postnatally. Therefore, bundled funding directly rewards services who provide care most efficiently, rather than rewarding those who deliver the most episodes and highest-cost procedures.

There is need for whole-of-system redesign that recognises MGP not only improves health outcomes (Sandall et al., 2016) and women’s experiences (Forster et al., 2016) –  but also reduces the cost of providing maternity care.

Highlighted research

Callander, E. J., Slavin, V., Gamble, J., Creedy, D. K., & Brittain, H. (2021). Cost-effectiveness of public caseload midwifery compared to standard care in an Australian setting: a pragmatic analysis to inform service delivery. International Journal for Quality in Health Care, 33(2). https://doi.org/10.1093/intqhc/mzab084

References

Council of Australian Governments. (2014). National Health Reform Agreement. COAG.

Forster, D. A., McLachlan, H. L., Davey, M. A., Biro, M. A., Farrell, T., Gold, L., Flood, M., Shafiei, T., & Waldenström, U. (2016). Continuity of care by a primary midwife (caseload midwifery) increases women’s satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial. BMC Pregnancy and Childbirth16, 28. https://doi.org/10.1186/s12884-016-0798-y

Gao, Y., Gold, L., Josif, C., Bar-Zeev, S., Steenkamp, M., Barclay, L., Zhao, Y., Tracy, S., & Kildea, S. (2014). A cost-consequences analysis of a midwifery group practice for Aboriginal mothers and infants in the top end of the Northern Territory, Australia. Midwifery30(4), 447–455. https://doi.org/10.1016/j.midw.2013.04.004

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. The Cochrane Database of Systematic Reviews4, CD004667. https://doi.org/10.1002/14651858.CD004667.pub5

Toohill, J., Turkstra, E., Gamble, J., & Scuffham, P. A. (2012). A non-randomised trial investigating the cost-effectiveness of Midwifery Group Practice compared with standard maternity care arrangements in one Australian hospital. Midwifery28(6), e874–e879.

Tracy, S.K., Welsh, A., Hall, B. et al. (2014). Caseload midwifery compared to standard or private obstetric care for first time mothers in a public teaching hospital in Australia: a cross sectional study of cost and birth outcomes. BMC Pregnancy Childbirth 1446.

Tracy, S. K., Hartz, D. L., Tracy, M. B., Allen, J., Forti, A., Hall, B., . . . Kildea, S. (2013). Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial. The Lancet, 382(9906), 1723-1732.

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

“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

Midwives’ social and emotional competence key to quality maternity care

Midwives social and emotional skills matter – they matter to women and families, and they matter when working in a maternity care team.  Social and emotional competence starts with self-awareness, identifying one’s own reactions to situations and people, then developing the ability to widen the gap between our reaction and our response. Managing and self-regulating the emotional response when communicating with others is key to sustaining positive relationships – including when conflict arises. But empathy, self-regulation and conflict resolution skills may not come naturally and are rarely taught in undergraduate midwifery programs (Hastie & Barclay, 2021).

Interactions within the healthcare team

Positive workplace culture and effective teams are built by staff who demonstrate social and emotional competence (Hughes & Albino, 2017; Black et al., 2019). When teamwork is compromised, often through negative workplace culture, it harms mothers and babies (Rönnerhag et al., 2019), and leads to staff burnout and high turnover (Catling et al., 2017). An Australian national survey of midwifery workplace culture largely described poor communication, lack of leadership and support, and bullying (Catling et al., 2020). Teamwork function is undermined by poor communication between team members, an absence of shared goals, or lack of social and emotional skills (Best & Kim, 2019).

Skills required for teamwork can be taught

PhD candidate Carolyn Hastie recently examined whether teaching and assessing teamwork skills prepares undergraduate midwifery students to be effective team members when they graduate (Hastie & Barclay, 2021 – see article here). The researchers analysed interviews with 19 early career midwives who had learnt, practised, and assessed each other on teamwork skills developed through group assignments in their Bachelor of Midwifery program.

Teamwork central to practice

The research found that in their first year, midwifery students did not appreciate how central teamwork was to their future practice as a midwife (Hastie & Barclay, 2021). Participants described that group assignments were hard and tiresome, and some wrote off social and emotional skills as less important and “fluffy”. However, as new graduates they reflected that teamwork at university had prepared them for teamwork in the hospital setting.

Conflict inevitable but manageable

The participants acknowledged that conflict was an inevitable part of midwifery work (Hastie & Barclay, 2021). Participants found they had learnt how not to take rude or challenging behaviour personally. They reflected that they were more likely to see the situation from the other person’s viewpoint. This stance helped them to regulate their emotional reactions and to respond in a more considered and constructive way.

Advocating for self and others

These midwives used strategies they had learnt to have courageous conversations and address issues early, with one stating “rather than letting it fester, nip it in the bud”. When interacting with colleagues, that could mean asking direct questions (e.g., what was your rationale?) – or providing an alternative viewpoint (i.e., politely disagreeing, and explaining why). These skills are particularly important in terms of speaking up for safety and advocating for women.

Recommendations for practice

Midwives can strengthen their social and emotional competence by increasing their self-awareness. This might include reflecting on difficult interactions in practice through journaling or debriefing with a trusted colleague, participating in clinical supervision, or learning and practising mindfulness. Maternity services should consider the social and emotional competencies managers and midwives need to contribute to an effective team and positive workplace culture – and which steps would increase staff capability. Social and emotional competence matters to safe, quality maternity care.

References 

Best, J. A., & Kim, S. (2019). The FIRST curriculum: Cultivating speaking up behaviors in the clinical learning environment. Journal of Continuing Education in Nursing, 50 (8) (2019), pp. 355-361. https://doi.org.10.3928/00220124-20190717-06

Black, J., Kim, K., Rhee, S., Wang, K., & Sakchutchawan, S. (2019). Self-efficacy and emotional intelligence. Team Performance Management: An International Journal, 25(1/2), 100-119. https://doi.org/10.1108/tpm-01-2018-0005

Catling, C. J., Reid, F., & Hunter, B. (2017).  Australian midwives’ experiences of their workplace culture. Women and Birth, 30(2) (2017), pp. 137-145. https://doi.org/10.1016/j.wombi.2016.10.001

Catling, C., & Rossiter, C. (2020). Midwifery workplace culture in Australia: A national survey of midwives. Women Birth, 33(5), 464-472. doi:10.1016/j.wombi.2019.09.008

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, 102997. https://doi.org/10.1016/j.midw.2021.102997

Hughes, M., & Albino, J. (2017). Assessing emotional and social intelligence for building effective hospital teams. The Psychologist-Manager Journal, 20(4), 208-221. https://doi.org/10.1037/mgr0000058

Rönnerhag, M., Severinsson, E., Haruna, M., & Berggren, I. (2019). A qualitative evaluation of healthcare professionals’ perceptions of adverse events focusing on communication and teamwork in maternity care. Journal of Advanced Nursing75(3), 585–593. https://doi.org/10.1111/jan.13864

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