News & Events

Tag Archives: Midwifery

Midwives are leaving the profession – could group clinical supervision help?

The world needs midwives

Maternal and infant health are a global priority. Midwives are pivotal to the wellbeing of women and their babies. Indeed, there is an urgent call to upscale midwifery to stem the rates of women and babies who are injured or die in childbirth. However, in Australia, like many other high-income countries, there is another type of crisis occurring that we can no longer ignore – midwives in significant numbers are leaving the profession.

Why midwives leave

Midwives are feeling demoralised, disempowered, and overwhelmed. Some of the reasons for this are medicalisation of birth, a lack of autonomy and under-staffing. These factors are leaving midwives emotionally fragile and feeling unsupported by their managers (Catling & Rossiter, 2020; Hunter et al, 2018; Pezaro et al. 2016).

There are heartbreaking accounts of midwives responding to this blog discussing the results of the Work, Health and Emotional Lives of Midwives (WHELM) study (Hunter et al, 2018). The WHELM study surveyed the wellbeing of nearly 2000 midwives in the UK and found significant levels of emotional distress, burnout, stress, anxiety, and depression. Two thirds of participants stated that they had thought about leaving their profession in the last six months, and alarmingly, early career midwives were over-represented in those leaving (Harvie et al, 2019).

Australian research echoes findings about midwives who have left the profession (Matthews, 2021), along with similar findings about work-related distress (Creedy et al., 2017; Catling & Rossiter, 2020). A Royal College of Midwives document Why midwives leave – revisited (2016) reported that 88% of midwives who had left the profession might consider returning if there were appropriate staffing levels. Eighty percent of midwives said they would return if their workplace culture was changed for the better, although this report did not outline what a positive workplace culture was.

Positive workplace culture

We suggest the following list (although not exhaustive) highlights some important things that midwives want from maternity services:

  • fully staffed ward/unit with adequate resources for staff to do their jobs;
  • visible managers who provide support to their staff to excel and flourish
  • support to engage in educational opportunities, support to attend conferences / seminars / complete higher degrees
  • emotional support following adverse events
  • timely feedback and assistance with relationships in the workplace including zero tolerance for bullying behaviour
  • autonomy in practice with multi-disciplinary assistance when indicated
  • opportunity to work in midwifery continuity of care

In essence, a positive workplace culture would have trust in, and collegiality with, work colleagues and knowledge that your work with women was high-quality and valuable.

How best to support midwives?

Clinical supervision is a well-known supportive strategy that has been used in many health disciplines to help promote staff professional development and health and wellbeing. Transforming Maternity Care Collaborative’s Director of Workforce, Associate Professor Christine Catling, gained a National Health and Medical Research Council investigator grant over the next 5 years to investigate whether group clinical supervision makes a difference to Australian midwives and the midwifery workplace culture.

The trial of group clinical supervision

The cluster randomised controlled trial (for maternity units in Greater Sydney) will involve 12 maternity sites (the ‘clusters’). Each cluster will be randomised to either receive the intervention (group clinical supervision) or not.

The trial will measure midwifery burnout rates (using the Copenhagen Burnout Inventory), the perceptions of their workplace culture (using the Australian Midwifery Workplace Culture tool), and intentions to leave the profession. For the intervention sites, the efficacy of the clinical supervision will be measured through using the Clinical Supervision Evaluation Questionnaire (Horton, 2008).

The results of this 5-year study are forthcoming. This year the research team will conduct a review of all available research evidence (both qualitative and quantitative) on group clinical supervision. Pending the study results, midwives and managers of maternity units could think about their workplace culture. Specifically, what they can do to build an environment where staff want to work, feel supported and feel safe.

References

Catling, C. & Rossiter, C. (2020). Midwifery workplace culture in Australia: A national survey of midwives. Women and Birth, 33(5), 464-472.

Creedy, DK., Sidebotham, M., Gamble, J., Pallant, J. & Fenwick, J. (2017). Prevalence of burnout, depression, anxiety and stress in Australian midwives: a cross-sectional survey. BMC Pregnancy and Childbirth, 17(1), 1-8.

Harvie K., Sidebotham, M. & Fenwick. J. (2019) Australian midwives’ intentions to leave the profession and the reasons why. Women and Birth, 32(6), e584-e593.

Horton S, de Lourdes Drachler M, Fuller A, de Carvalho Leite JC. (2008). Development and preliminary validation of a measure for assessing staff perspectives on the quality of clinical group supervision. International Journal of Language and Communication Disorders, 43, 126–34.

Hunter B, Henley J, Fenwick J et al. (2018). Work, Health and Emotional Lives of Midwives in the United Kingdom: The UK WHELM study. School of Healthcare Sciences, Cardiff University.

Matthews, R. (2021). Impact of stage of career on burnout and experience of work for midwives and neonatal nurses working in a tertiary service. Paper presented at the PSANZ Digital Congress.

Pezaro, S., Clyne, W., Turner, A., Fulton, E. & Gerada, C. (2016). ‘Midwives Overboard!’ Inside their hearts are breaking, their makeup may be flaking but their smile still stays on, Women and Birth, 29(3), e59-e66.

Royal College of Midwives. (2016). Why midwives leave – revisited. RCM, London.

Home-visiting in early labour may reduce fear and better meet women’s needs

Key issues in early labour

Early labour at home is a significant component of women’s birth experience. Women commonly feel fear and uncertainty in early labour and seek reassurance (Barnett, Hundley, Cheyne, & Kane, 2008), yet midwifery support is often limited. Fear, stress, and anxiety during childbearing inhibit labour progress (Buckley, 2015) and increase their perception of pain (Floris & Irion, 2015). If women are admitted in early labour, clinicians are more likely to intervene too soon by augmenting labour and offering epidural analgesia (Davey, McLachlan, Forster, & Flood, 2013; Neal et al., 2014) – even if labour progress is within normal limits (Zhang, 2010).

Regardless of model of care, telephone triage is routinely used for early labour assessment (Kobayashi et al., 2017). When women experience signs of labour, they usually contact either their own midwife (caseload midwifery) or the midwife on shift in the hospital assessment unit (standard care). When midwives assess  that women are in early labour, they advise them to stay at home, rest, eat, hydrate, mobilise and consider comfort strategies (Queensland Health Guidelines, 2018). However, research has shown that women are largely dissatisfied with telephone assessment in early labour. Participants describe unclear advice, unmet needs, unaddressed anxieties, and negative midwife manner (Green, Spiby, Hucknall, & Richardson Foster, 2012).

The M@NGO trial 6-week survey

A study from a large RCT of caseload midwifery, called the M@NGO trial, was the first to look at Australian women’s experience of early labour care (Allen et al., 2020). Participants were allocated to either caseload midwifery or standard fragmented care. Neither group were provided with midwife home visits during early labour. About 1,000 women (58% of M@NGO trial participants) completed a survey 6-weeks after birth. The 6-week survey included five questions that invited free-text answers. The free text data were analysed to determine categories – early labour care was one of them.

Analysis of women’s survey responses

The joint first authors searched the free text data to identify relevant phrases (such as ‘early’, ‘went to hospital’, ‘telephone’, ‘sent home’, ‘return’). They determined which comments were about early labour and analysed them to develop three themes to capture what women said. The researchers selected quotes to illustrate and validate the themes. Finally, the researchers used a critical lens to synthesise and explain the findings. To do this, they focussed on larger social forces and structures that impact how labour and birth is constructed (as something frightening and needing medical attention) and how maternity care is provided (institutionalised vs. individualised care).

Women’s experiences

The data included unique responses from 84 women: 44 in caseload care and 40 in standard care. Women’s views about early labour care were:

  1. they needed permission to come to hospital;
  2. they felt like if they came to hospital in early labour, they had done the “wrong” thing;
  3. midwives dismissed their experiences in early labour.

Critical analysis of the data generated two further themes to explain women’s experiences: women seeking and midwives shielding. Women in early labour sought care because they wanted to be close to those who knew what was going on. Medicine sends the message that birth is dangerous outside of hospital (Roome, Hartz, Tracy, & Welsh, 2015) – so this is understandable behaviour. Whereas by delaying presentation to hospital or sending women home, midwives were effectively shielding the hospital (and in caseload midwifery, their time) to protect resources. Midwives may also have been shielding women from the cascade of intervention.

Limitations of this study

This study did not collect data from midwives about early labour care. For the women who answered the survey, having their own midwife in caseload midwifery did not protect women against having negative experiences of early labour care. However, it remains possible that women who had positive experiences did not report on them in the survey.

Strategies to improve early labour care

Three strategies have been trialled to improve maternal and neonatal outcomes include: 1) early labour assessment vs. immediate admission;  2) home visits vs. telephone triage, and 3) one-to-one structure care vs. usual care) (Kobayashi et al., 2017). Of these three strategies, only early labour assessment made a difference to outcomes – shorter labour duration (average 5 hours), less epidural analgesia (13% less likely), and much less oxytocin augmentation (43% less likely) (Kobayashi et al., 2017). While early labour home visits do not appear to impact outcomes, they are  known to increase women’s satisfaction with care (Janssen & Desmarais, 2013). Another strategy is a dedicated early labour area for women who prefer to stay in hospital rather than return home. A comparison of intervention rates and birth outcomes before, and after, this area was introduced in a large Australian maternity hospital, found it made no difference to outcomes (Williams et al., 2020).

How can health services respond to women’s needs in early labour?

Women require support in early labour, not just assessment (Allen et al, 2020).  Midwives need to understand that emotional support is a valid and important part of their role (O’Connell & Downe, 2009). Health service managers should recognise that early labour is important to women and adjust the service model accordingly. To do this, services could evaluate women’s current satisfaction with early labour care (in all models of care) and then codesign a strategy to promote positive experiences. For caseload midwifery models in particular, evaluation of early labour home-visiting may be a feasible and valuable option.

References

Allen, J., Jenkinson, B., Tracy, S. K., Hartz, D. L., Tracy, M., & Kildea, S. (2020). Women’s unmet needs in early labour: Qualitative analysis of free-text survey responses in the M@NGO trial of caseload midwifery. Midwifery, 88, 102751. https://doi.org/10.1016/j.midw.2020.102751

Barnett, C., Hundley, V., Cheyne, H., & Kane, F. (2008). ‘Not in labour’: impact of sending women home in the latent phase. British Journal of Midwifery, 16(3), 144-153. https://doi.org/10.12968/bjom.2008.16.3.28692

Buckley, S. J. (2015). Executive Summary of Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care. Journal of Perinat al Education, 24(3), 145-153. https://doi.org/10.1891/1058-1243.24.3.145

Davey, M., McLachlan, H., Forster, D., & Flood, M. (2013). Influence of timing of admission in labour and management of labour on method of birth: Results from a randomised controlled trial of caseload midwifery (COSMOS trial). Midwifery, 29(12), 1297 – 1302.  https://doi.org/10.1016/j.midw.2013.05.014

Floris, L., & Irion, O. (2015). Association between anxiety and pain in the latent phase of labour upon admission to the maternity hospital: a prospective, descriptive study. J ournal of Health Psychology, 20(4), 446-455. https://doi.org/10.1177/1359105313502695

Green, J. M., Spiby, H., Hucknall, C., & Richardson Foster, H. (2012). Converting policy into care: women’s satisfaction with the early labour telephone component of the All Wales Clinical Pathway for Normal Labour. J ournal of Adv anced Nursing, 68(10), 2218-2228. https://doi.org/10.1111/j.1365-2648.2011.05906.x

Janssen, P., & Desmarais, S. L. (2013). Women’s experience with early labour management at home vs. in hospital: a randomised controlled trial. Midwifery, 29(3), 190-194. https://doi.org/10.1016/j.midw.2012.05.011

Kobayashi, S., Hanada, N., Matsuzaki, M., Takehara, K., Ota, E., Sasaki, H., . . . Mori, R. (2017). Assessment and support during early labour for improving birth outcomes. Cochrane Database of Systematic Reviews, 4(4), Cd011516. https://doi.org/10.1002/14651858.CD011516.pub2

Neal, J. L., Lamp, J. M., Buck, J. S., Lowe, N. K., Gillespie, S. L., & Ryna, S. L. (2014). Outcomes of nulliparous women with spontaneous labor onset admitted to hospitals in preactive versus active labor. Journal of Midwifery & Women’s Health, 59(1), 28-34. https://doi.org/10.1111/jmwh.12160

O’Connell, R., & Downe, S. (2009). A metasynthesis of midwives’ experience of hospital practice in publicly funded settings: compliance, resistance and authenticity. Health, 13(6), 589-609. https://doi.org/10.1177/1363459308341439

Queensland Clinical Guidelines. (2018). Queensland Maternity and Neonatal Clinical Guideline: Normal birth. (MN17.25-V3-R22). Brisbane: Queensland Health Retrieved from https://www.health.qld.gov.au/qcg/documents/g_normbirth.pdf

Williams, L., Jenkinson, B., Lee, N., Gao, Y., Allen, J., Morrow, J., & Kildea, S. (2020). Does introducing a dedicated early labour area improve birth outcomes? A pre-post intervention study. Women and Birth, 33(3), 259-264. https://doi.org/10.1016/j.wombi.2019.05.001

Zhang, J., Landy, H. J., Branch, D. W., Burkman, R., Haberman, S., Gregory, K. D., . . . Reddy, U. M. (2010). Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes. Obstetrics and Gynecology, 116(6), 1281-1287. https://doi.org/10.1097/AOG.0b013e3181fdef6e

Preterm birth and the cost to women

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

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

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

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

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

References

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

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

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

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

Making continuity of care experiences work for midwifery students

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

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

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

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

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

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

References

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

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

Bundles for perineal care: the impact on midwifery practice

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

 

Preparing students to provide continuity of care

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

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

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

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

References

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

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

Midwifery students and birthing women: a valuable relationship

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References 

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

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

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

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

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

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

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

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

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

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

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

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

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

No Pain, No Gain? An opinion piece

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

No Pain, No Gain?

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

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

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

History

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

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

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

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

Biomedical Paradigm

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

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

Physiological vs medical approaches to pain

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

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

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

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

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

Power Play

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

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

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

Pain relief is a human right!

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

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

Reframing non-pharmacological pain relief

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MacIvor Thompson, L. (2019). The politics of female pain: women’s citizenship, twilight sleep and the early birth control movement. Medical Humanities, 45(1), 67. https://doi.org/10.1136/medhum-2017-011419

Mills, T. A., Ricklesford, C., Heazell, A. E. P., Cooke, A., & Lavender, T. (2016, 2016/05/06). Marvellous to mediocre: findings of national survey of UK practice and provision of care in pregnancies after stillbirth or neonatal death. BMC Pregnancy and Childbirth, 16(1), 101. https://doi.org/10.1186/s12884-016-0891-2

Nodine, P. M., Collins, M. R., Wood, C. L., Anderson, J. L., Orlando, B. S., McNair, B. K., Mayer, D. C., & Stein, D. J. (2020). Nitrous oxide use during labor: Satisfaction, adverse effects, and predictors of conversion to neuraxial analgesia. Journal of Midwifery & Women’s Health, 65(3), 335-341. https://doi.org/10.1111/jmwh.13124

Queensland Clinical Guidelines. (2017). Normal Birth. https://www.health.qld.gov.au/__data/assets/pdf_file/0014/142007/g-normalbirth.pdf

Sanders, R. (2015, 2015/09/01/). Functional discomfort and a shift in midwifery paradigm. Women and Birth, 28(3), e87-e91. https://doi.org/https://doi.org/10.1016/j.wombi.2015.03.001

Sanders, R. A., & Lamb, K. (2017). Non-pharmacological pain management strategies for labour: Maintaining a physiological outlook. British Journal of Midwifery, 25(2), 78-85. https://doi.org/10.12968/bjom.2017.25.2.78

Skowronski, G. A. (2015). Pain relief in childbirth: changing historical and feminist perspectives. Anaesthesia and Intensive Care, 43, 25-28. http://hy8fy9jj4b.search.serialssolutions.com/directLink?&atitle=Pain+relief+in+childbirth%3A+changing+historical+and+feminist+perspectives&author=Skowronski%2C+G+A&issn=0310057X&title=Anaesthesia+and+Intensive+Care&volume=43&issue=&date=2015-07-01&spage=25&id=doi:&sid=ProQ_ss&genre=article

Smith, L. A., Burns, E., & Cuthbert, A. (2018). Parenteral opioids for maternal pain management in labour. Cochrane Database of Systematic Reviews(6). https://doi.org/10.1002/14651858.CD007396.pub3

Spendlove, Z. (2018). Risk and boundary work in contemporary maternity care: tensions and consequences. Health, Risk & Society, 20(1/2), 63-80. https://doi.org/10.1080/13698575.2017.1398820

Thomson, G., Feeley, C., Moran, V. H., Downe, S., & Oladapo, O. T. (2019). Women’s experiences of pharmacological and non-pharmacological pain relief methods for labour and childbirth: a qualitative systematic review. Reproductive health, 16(1), 71-20. https://doi.org/10.1186/s12978-019-0735-4

Wickham, S. (2016). Whatever happened to the precautionary principle? https://www.sarawickham.com/articles-2/whatever-happened-to-the-precautionary-principle/

Wood, W. (2018). Shifting understandings of labour pain in Canadian medical history. Medical Humanities, 44(2), 82-88. https://doi.org/10.1136/medhum-2017-011417

World Health Organisation. (2015). WHO Statement on Caesarean Section Rates. https://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf;jsessionid=9813B3D2910219254542B7A550D264B7?sequence=1

Do soft fairy lights matter during birth? 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 third of five articles in a series. The author of this article preferred to publish anonymously. 

Do soft fairy lights matter?

There is an increasing interest in women customising and changing their birthing environments by adding such things as candles, fairy lights, and motivational posters to make the space their own.  In addition, we are seeing more consumer demand for birthing rooms that feel less like a hospital room and more like a hotel or home environment.  But does the birthing environment actually matter? Are there environments that promote normal physiological birth?  Does creating a birth environment that feels safe and secure to the woman affect outcomes?  Do midwives have a role in facilitating this?

Modern day Australia says the birth environment doesn’t matter…

Generally speaking, modern day, mainstream Australia doesn’t value the birth environment and its effect on birth.  Research shows that women who want to engage in changing their birth environment – having music, candles, and the room dimly lit – are often received with disrespect and perceived to be controlling by the general public. Birth stories are told and passed down through generations, shared between friends over coffee, and often focus more on the negative than the positive. Any pregnant woman will tell you that unsolicited labour and birth horror stories start the moment her pregnancy is public. The main storyline? It’s terrifying. It is rare to hear of women birthing at home, with very few publicly funded home birth options available.  While this is slowly changing, the norm is still a hospital birth, under the care of an obstetrician, with midwives providing care during labour and birth.

Has birth become over-medicalised?

In the 18th century most women gave birth in their own home, with a midwife in attendance, surrounded by female family members.  Yet currently in Australia, 96% of women birth in a hospital, with less than 4% birthing at home, in a birth centre or before arrival at hospital.  Australia, like most developed countries, is over-medicalised and operates from a bio-medical model of care (Germov, 2014).  This bio-medical model looks primarily at physical illness and focuses on diagnosis and treatment.  Over-medicalisation and the biomedical model is a widely accepted norm in western societies and which regards pregnancy and birth in the same way: diagnosis (pregnancy) and treatment (delivery of the baby) (Germov, 2014).  Over the last one hundred or so years, birth has slowly been taken out of the community and put into the medical model.  This process, of separating the woman from her own home and familiar environment, and surrounding her with strangers and technology at such an intimate and private time, has only worked to de-humanise birth.

Most Australians, in most circumstances, submit to this medical model, leaving power in the hands of doctors and medical practitioners, and holding them as the ultimate experts.  This medicalised model places an emphasis on risk, and a pressure to conform and accept the environment.  Midwives are required to be the guardians that facilitate this birth environment.

What does media tell us about birth?

Not surprisingly, the media portrays childbirth as a painful, dramatic, and distressing experience.  Women are rarely seen off the bed, and doctors are seen as the experts who arrive in just time to “deliver” the woman from this difficult situation.  A birth room analysis study, completed in 2015, collected images from Google, Wikipedia etc. of midwifery units in developed countries to ascertain the message being sent about labour rooms.  While three primary categories were identified; the technological, the home-like and the hybrid domesticated birth room, the dominant was the technological birth room.  This type of room pictured the bed in the centre, surrounded by medical equipment.  The message? Birth is risky and dangerous and you need this technological environment to give birth.  One needs to ask: What does this do to the woman? How does it make her feel?

As identified earlier, the media plays a role in framing birth for the general public (Germov, 2014).  In 2014, a survey of young Australian women who had no children, highlighted that a disproportionate number of births on TV showed disasters and emergency situations.  However, the landscape has changed since the advent of social media sites, with many traditional media trying to adapt over the last decade.  With the advent of social media, streaming sites, and a plethora of podcasts, different types of birth stories are being told and seen.  More stories of women birthing at home or in a birthing pool, in a birth centre and stories of women owning their birth space are emerging.

Tell me about the hormones…

Physiology teaches us about the way the body works: that oxytocin, what we call the “love” hormone, is needed for the uterus to contract, and labour to continue.  In fact it is a manufactured oxytocin that is often given to women to induce or speed up a slow labour (Stables & Rankin, 2010).  Oxytocin is released into the brain as a result of a stimulus, such as social contact, physical touch, or skin to skin contact (Stables & Rankin, 2010).  When we are fearful, our ‘fight or flight’ reaction kicks in, releasing adrenaline into our system.  This disrupts the production of oxytocin and interferes with labour (Stables & Rankin, 2010).  Research has shown that the ideal birthing space is a sanctum in which women feel they have privacy, and are at ease and comfortable. This comfort is key for optimum physiological function and for women’s emotional wellbeing during labour and birth.  Birth room surveillance, and use of high technology, has been shown to increase stress for women; and may continue to cause a cascade of hormonal imbalances that have negative consequences.  As identified earlier, the increase in adrenaline results in a decrease in oxytocin; slowing down labour.  Additionally, the vasoconstrictive effect of adrenaline may divert blood from the placenta, which can lead to a decrease in fetal oxygenation and therefore fetal distress.

Women need to feel safe and secure in labour and birth to have that natural increase in oxytocin and encourage physiologic birth.  The Room4birth study currently being undertaken in Sweden, allocates women in spontaneous labour to either a standard medicalised room or a newly designed birthing room that can be adapted to the woman’s desires (lights, media installation, silencer, bathtub).  The study will measure physical outcomes as well as women’s experiences.  In addition, another study on the effects of the birthing room is currently being undertaken in Germany, again assessing physical outcomes and maternal satisfaction.

What do midwives say…?

Midwives know that to facilitate normal, physiological birth they influence the birth environment to create a safe and private space.  While home is cited as the ideal place for normal birth, hospital birthing rooms can be designed and adapted to create a home-like environment that is low tech. Midwives believe it is part of their role to guard the space for women, not just physically but emotionally too,  particularly in a bio-medical model that emphasises risk and where surveillance is commonplace.

Midwives consider a supportive environment to be critical and of paramount importance to facilitating a physiologically normal birth.  Dim lighting, a quiet space, and limiting people coming in and out of the room are all considered important in creating this intimate space.  Additionally, midwives often consider themselves protectors of this space and an emotional support for the woman and her family, while encouraging mobility and movement.  Midwives are not only best placed to educate and inform women about their rights and the benefits of creating such a space, and are well placed to protect this birthing space physically and emotionally, it is also part of their professional obligation.

But what about…?

The question is often asked – what about women who have their babies on the side of the road? Or during natural disasters? In situations where they don’t feel safe?  This is the wrong question to ask, because it dismisses women’s right for birthing in an environment that they feel comfortable, private and secure in.  These situations are rare and extreme, and preclude any control of the environment.  Because women can and do give birth in stressful and traumatic situations does not negate the fact that women have the choice to change and alter their birth environment.  While more research should be undertaken for women birthing in these emergency situations, it does not negate what we already know about the effect of hormones and environment on labouring women.

Birth environment does matter

Current research shows that the birthing environment does matter, and that, to increase the chance of a physiologically normal birth, women need to feel safe and secure.  Research also shows that women reported greater satisfaction with care and a decrease in pain intensity after birthing rooms had been redesigned. Women should be encouraged to take control of their birthing environments, to do what they need in order to create a space that feels peaceful, secure and safe.  That space will look different for each woman and may well include fairy lights!

References

Australian Institute of Health and Welfare. (2018). Australia’s mothers and babies data visualisations https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies-data-visualisations/contents/labour-and-birth/place-of-birth

Ayerle, G. M., Schäfers, R., Mattern, E., Striebich, S., Haastert, B., Vomhof, M., Icks, A., Ronniger, Y., & Seliger, G. (2018). Effects of the birthing room environment on vaginal births and client-centred outcomes for women at term planning a vaginal birth: BE-UP, a multicentre randomised controlled trial. Trials, 19(1), 641-613. https://doi.org/10.1186/s13063-018-2979-7

Berg, M., Goldkuhl, L., Nilsson, C., Wijk, H., Gyllensten, H., Lindahl, G., Uvnäs Moberg, K., Begley, C., Göteborgs, u., Gothenburg, U., Centrum för personcentrerad vård vid Göteborgs, u., Sahlgrenska, A., Sahlgrenska, a., University of Gothenburg Centre for person-centred, c., Institutionen för vårdvetenskap och, h., Institute of, H., & Care, S. (2019). Room4Birth – the effect of an adaptable birthing room on labour and birth outcomes for nulliparous women at term with spontaneous labour start: study protocol for a randomised controlled superiority trial in Sweden. Trials, 20(1), 629-612. https://doi.org/10.1186/s13063-019-3765-x

Bowden, C., Sheehan, A., & Foureur, M. (2016). Birth room images: What they tell us about childbirth. A discourse analysis of birth rooms in developed countries. Midwifery, 35, 71-77. https://doi.org/10.1016/j.midw.2016.02.003

Butler, M. M. (2017). Exploring the strategies that midwives in British Columbia use to promote normal birth. BMC Pregnancy and Childbirth, 17(1), 168-112. https://doi.org/10.1186/s12884-017-1323-7

Carolan-Olah, M., Kruger, G., & Garvey-Graham, A. (2015). Midwives׳ experiences of the factors that facilitate normal birth among low risk women at a public hospital in Australia. Midwifery, 31(1), 112-121. https://doi.org/10.1016/j.midw.2014.07.003

D’Cruz, L., & Lee, C. (2014). Childless expecttions: an Australian study of young childless women. Journal of Reproductive and Infant Psychology, 32(2), 199-211. https://doi.org/10.1080/02646838.2013.875134

Fahy, K. M., & Parratt, J. A. (2006). Birth Territory: A theory for midwifery practice. Women and Birth, 19(2), 45-50. https://doi.org/10.1016/j.wombi.2006.05.001

Foureur, M., Davis, D., Fenwick, J., Leap, N., Iedema, R., Forbes, I., & Homer, C. S. E. (2010). The relationship between birth unit design and safe, satisfying birth: Developing a hypothetical model. Midwifery, 26(5), 520-525. https://doi.org/10.1016/j.midw.2010.05.015

Germov, J. (2014). Second Opinion: An Introduction to Health Sociology (5th ed.). Oxford University Press.

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

Moscucci, O. (1993). The Science of woman: Gynaecology and Gender in England, 1800 – 1929. https://books.google.co.uk/books?id=szmnVZs_ImsC&pg=PA42&source=gbs_toc_r&hl=en – v=onepage&q&f=false

Nusing and Midwifery Board of Australia. (2018). Midwife Standards for Practice. https://doi.org/https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/Midwife-standards-for-practice.aspx

Seibold, C., Licqurish, S., Rolls, C., & Hopkins, F. (2010). ‘Lending the space’: Midwives perceptions of birth space and clinical risk management. Midwifery, 26(5), 526-531. https://doi.org/10.1016/j.midw.2010.06.011

Stables, D., & Rankin, J. (2010). Physiology in Childbearing with Anatomy and Related Biosciences (3rd Edition ed.). Elsevier Limited.

Stenglin, M., & Foureur, M. (2013). Designing out the fear cascade to increase the likelihood of normal birth. Midwifery, 29(8), 819-825. https://doi.org/10.1016/j.midw.2013.04.005

Wagner, M. (2001). Fish can’t see water: the need to humanize birth. International Journal of Gynaecology and Obstetrics, 75 Suppl 1, S25. https://birthinternational.com/article/birth/fish-cant-see-water/

Welbers, K., & Opgenhaffen, M. (2018). Social media gatekeeping: An analysis of the gatekeeping influence of newspapers’ public Facebook pages. New Media & Society, 20(12), 4728-4747. https://doi.org/10.1177/1461444818784302