Birthing outside the system : the motivation behind the choice to freebirth or have a homebirth with risk factors in Australia

Background: Childbirth in Australia occurs predominantly in a biomedical context, with 97% of births occurring in hospital. A small percentage of women choose to birth outside the system – that is, to have a midwife attended homebirth with risk factors, or a freebirth, where the birth at home is intentionally unattended by any health professional. Method: This study used a Grounded Theory methodology. Data from 13 women choosing homebirth and 15 choosing freebirth were collected between 2010 and 2014 and analysed over this time. Results: The core category was ‘wanting the best and safest,’ which describes what motivated the women to birth outside the system. The basic social process, which explains the journey women took as they pursued the best and safest, was ‘finding a better way’. Women who gave birth outside the system in Australia had the countercultural belief that their knowledge about what was best and safest had greater authority than the socially accepted experts in maternity care. The women did not believe the rhetoric about the safety of hospitals and considered a biomedical approach towards birth to be the riskier birth option compared to giving birth outside the system. Previous birth experiences taught the women that hospital care was emotionally unsafe and that there was a possibility of further trauma if they returned to hospital. Giving birth outside the system presented the women with what they believed to be the opportunity to experience the best and safest circumstances for themselves and their babies. Conclusion: Shortfalls in the Australian maternity care system is the major contributing factor to women’s choice to give birth outside the system. Systematic improvements should prioritise humanising maternity care and the expansion of birth options which prioritise midwifery-led care for women of all risk

Expectations of the upcoming birth : a survey of women's self-efficacy and birth positions

Background: Adopting an upright sacrum flexible position may facilitate physiological childbirth, which many pregnant women wish for. A positive association between women's choice on birthing position and birthing experience has been found. Objective: The aim of this study was to examine women's preferred birth position, self-efficacy at term and their actual birth position at time of birth. Methods: A survey of 554 pregnant Danish women at gestational week 38. Data was collected using an online survey and information was retracted from the woman's medical record. Descriptive statistics and non-parametric tests were used and univariate and multivariate logistic regression models were used to analyse the association between self-efficacy and fulfilled wish of birth position. Findings: The majority of women (>70 %) wished to give birth in a sacrum flexible position but more than 80 % gave birth in a non-flexible position. Less than 50 % had their wish of birth position fulfilled. All women reported overall high self-efficacy. No difference in having wish for birth position fulfilled was found comparing women with high and low self-efficacy. Conclusions: Most women wished for a sacrum flexible position but more than 80% gave birth in a sacrum non-flexible position and less than 50% had their wish for birth position fulfilled. Level of self-efficacy did not affect the likelihood of having wish of birth position fulfilled indicating that the culture at the birth setting and skills and attitudes among birth providers may have a considerable impact on women's choice of birth position

"You are either with me on this or not" : a meta-ethnography of the influence birth partners and care-providers have on coping strategies learned in childbirth education and used by women during labour

Background: Childbirth education, which includes providing information and practical techniques to help manage childbirth, aims to support women and their birth partners. It is unknown how birth partners and care providers influence the utilisation of childbirth education information and techniques during women's labour and birth. Aim: To explore the literature that investigates the influence that birth partners and care-providers have on the application of childbirth education information and techniques used by women during childbirth. Methods: A meta-ethnography was performed using a systematic synthesis of reciprocal translation and refutational investigation. There were 22 papers included in the final synthesis. Quality appraisal was undertaken using the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBIQARI) quality appraisal tool for qualitative studies. Findings: An over-arching theme of ‘you are either with me on this or not’ emerged from the data, which expressed the positive and negative influences on the use of childbirth education information and techniques during labour and birth. The influence of birth partners was captured in the themes ‘stepping up to their full potential’ and ‘a spare part’. The themes ‘in alignment with the woman’ and ‘managed by another’ were conceptualised from the data in relation to care-providers’ influence. A theme, ‘the right fit’, described organisational and contextual influences. Conclusion: Birth partners and care-providers who are present during a woman's labour have significant potential to influence her use of childbirth education strategies in labour, which provides important insights for translation of evidence into practice

Women's experiences of changes to childbirth and parenting education in Australia during the COVID-19 pandemic : the birth in the time of COVID-19 (BITTOC) study

Objective: As changes to Childbirth and Parenting Education (CBPE) classes during the COVID-19 pandemic remain unexplored in Australia, our objective was to understand how changes to CBPE in Australia during the COVID-19 pandemic impacted on women’s birth and postnatal experiences. Methods: Survey responses were received from 3172 women (1343 pregnant and 1829 postnatal) for the ‘Birth In The Time Of Covid-19 (BITTOC)’ survey (August 2020 to February 2021) in Australia. One of the survey questions asked women if they had experienced changes to CBPE class schedules or format during the pandemic, with a follow up open ended text box inviting women to comment on the impact of these changes. The majority of women experienced changes to CBPE, with only 9 % stating they experienced no changes to classes. A content analysis was undertaken on the 929 open text responses discussing the impact these changes had on women’s experience of pregnancy, birth and postpartum. Results: 929 women (29 %) made 1131 comments regarding changes to CBPE classes during the pandemic. The main finding ‘I felt so unprepared’, highlights how women perceived the cessation or alteration of classes impacted their birth preparation, with many reporting an increased sense of isolation. Some women reported feeling ‘It was good enough’ with adequate provision of online classes, and others feeling ‘I was let down by the system’ due to communication and technological barriers. Conclusions: Results highlight the importance of ensuring continued provision of hybrid/online childbirth education models to enable versatility during times of crisis. Gaps in service provision, communication and resources for childbirth and parenting education need addressing

From coercion to respectful care : women’s interactions with health care providers when planning a VBAC

Background: In many countries caesarean section rates are increasing and this impacts on choices made around mode of birth in subsequent pregnancies. Having a vaginal birth after caesarean (VBAC) can be a safe and empowering experience for women, yet most women have repeat caesareans. High caesarean section rates increase maternal and neonatal morbidity, health costs and burden on hospitals. Women can experience varied support from health care providers when planning a VBAC. The aim of this paper is to explore the nature and impact of the interactions between women planning a VBAC and health care providers from the women’s perspective. Methods: A national Australian VBAC survey was undertaken in 2019. In total 559 women participated and provided 721 open-ended responses to six questions. Content analysis was used to categorise respondents’ answers to the open-ended questions. Results: Two main categories were found capturing the positive and negative interactions women had with health care providers. The first main category, ‘Someone in my corner’, included the sub-categories ‘belief in women birthing’, ‘supported my decisions’ and ‘respectful maternity care’. The negative main category ‘Fighting for my birthing rights’ included the sub-categories ‘the odds were against me’, ‘lack of belief in women giving birth’ and ‘coercion’. Negative interactions included the use of coercive comments such as threats and demeaning language. Positive interactions included showing support for VBAC and demonstrating respectful maternity care. Conclusions: In this study women who planned a VBAC experienced a variety of positive and negative interactions. Individualised care and continuity of care are strategies that support the provision of positive respectful maternity care

Jordanian women's experiences and constructions of labour and birth in different settings, over time and across generations : a qualitative study

Background: Overwhelmingly, women in Middle Eastern countries experience birth as dehumanising and disrespectful. Women’s stories can be a very powerful way of informing health services about the impact of the care they receive and can promote practice change. The aim of this study is to examine Jordanian women’s experiences and constructions of labour and birth in different settings (home, public and private hospitals in Jordan, and Australian public hospitals), over time and across generations. Method: A qualitative interpretive design was used. Data were collected by face-to-face semi-structured interviews with 27 Jordanian women. Of these women, 20 were living in Jordan (12 had given birth in the last five years and eight had birthed over 15 years ago) while seven were living in Australia (with birthing experience in both Jordan and Australia). Interview data were transcribed verbatim and analysed thematically. Results: Women’s birth experiences differed across settings and generations and were represented in the four themes: ‘Birth at home: a place of comfort and control’; ‘Public Hospital: you should not have to suffer’; ‘Private Hospital: buying control’ and ‘Australian maternity care: a mixed experience’. In each theme, the concepts: Pain, Privacy, the Personal and to a lesser extent, Purity (cleanliness), were present but experienced in different ways depending on the setting (home, public or private hospital) and the country. Conclusions: The findings demonstrate how meanings attributed to labour and birth, particularly the experience of pain, are produced in different settings, providing insights into the institutional management and social context of birth in Jordan and other Middle Eastern countries. In the public hospital environment in Jordan, women had no support and were treated disrespectfully. This was in stark contrast to women birthing at home only one generation before. Change is urgently needed to offer humanised birth in the Jordanian maternity system

How do anxiety and relationship factors influence the application of childbirth education strategies during labor and birth : a Bowen family systems perspective

The effectiveness of childbirth education (CBE) has long been debated with studies showing contradictory outcomes for mothers and babies. Understanding how what is learned in CBE is translated into practice during labor and birth is an area that requires investigation as this may be a mediating factor in its effectiveness. Bowen family system theory’s concept of differentiation of self, the ability to be guided by and to act from one’s beliefs and values, is an organizing principle that may affect how relational factors affect the use and application of CBE at the time of birth. The ability to act with emotional maturity when faced with a stressor, such as childbirth, depends on an individual’s capability to separate thoughts from the more reactive feeling process. Recognizing how one’s level of differentiation interacts with the anxious responses of others may assist pregnant women and birth partners to make decisions more objectively about how they want to manage the birthing process. For the health professional, understanding the interplay of relationship variables, physiological stress, anxiety and individual reactivity may allow for the provision of more thoughtful evidence-based practice, which may increase objectivity, and aid communication and decision-making for women during birth. Bowen theory, as a comprehensive systems-based approach to understanding human functioning under stress, offers a novel approach to exploring the application of CBE during birth

Is a randomized controlled trial of waterbirth possible? : an Australian feasibility study

Background: The safety of waterbirth is contested because of the lack of evidence from randomized trials and conflicting results. This research assessed the feasibility of a prospective study of waterbirth (trial or cohort). Methods: We conducted a prospective cohort study at an Australian maternity hospital. Eligible women with uncomplicated pregnancies at 36 weeks of gestation were recruited and surveyed about their willingness for randomization. The primary midwife assessed waterbirth eligibility and intention on admission in labor, and onset of second stage. Primary outcomes measured feasibility. Intention-to-treat analysis, and per-protocol analysis, compared clinical outcomes of women and their babies who intended waterbirth and nonwaterbirth at onset of second stage. Results: 1260 participants were recruited; 15% (n = 188) agreed to randomization in a future trial. 550 women were analyzed by intention-to-treat analysis: 351 (waterbirth) and 199 (nonwaterbirth). In per-protocol analysis, 14% (n = 48) were excluded. Women in the waterbirth group were less likely to have amniotomy and more likely to have water immersion and physiological third stage. There were no differences in other measures of maternal morbidity. There were no significant differences between groups for serious neonatal morbidity; four cord avulsions occurred in the waterbirth group with none in the landbirth group. An RCT would need approximately 6000 women to be approached at onset of second stage. Conclusions: A randomized trial of waterbirth compared with nonwaterbirth, powered to detect a difference in serious neonatal morbidity, is unlikely to be feasible. A powered prospective study with intention-to-treat analysis at onset of second stage is feasible

Obstetric and psychosocial risk factors for Australian-born and non-Australian born women and associated pregnancy and birth outcomes : a population based cohort study

Background: One in four Australians is born overseas and 47 % are either born overseas or have a parent who was. Obstetric and psychosocial risk factors for these women may differ. Method: Data from one Sydney hospital (2012–2013) of all births recorded in the ObstetriX™ database were analysed (n = 3,092). Demographics, obstetric and psychosocial risk profile, obstetric interventions and complications and selected maternal and neonatal outcomes were examined for women born in Australia and overseas. Results: Women born in Australia were younger, more likely to be primiparous (28.6 v 27.5 %), be obese (32.0 % v 21.4 %), smoke (19.7 % v 3.0 %), have an epidural (26.2 % v 20.2 %) and were less likely to have gestational diabetes mellitus (GDM) (6.8 % v 13.7 % when compared to non-Australian born women. The highest rates of GDM, Gestational Hypertension (GH) and maternal anaemia were seen in women born in China, the Philippines and Pakistan respectively. Differences were also seen in psychosocial screening between Australian and non-Australian women with Australian-born women more likely to smoke and report a mental health disorder. There was an association between having an Edinburgh Postnatal Depression Scale (EPDS) ≥ 13 and other psychosocial issues, such as thoughts of self-harm, domestic violence, childhood abuse etc. These women were also less likely to breastfeed. Women with an EPDS ≥ 13 at booking compared to women with EPDS ≤12 had a higher chance of being diagnosed with GDM (AOR 1.85 95 % CI 1.14–3.0). Conclusions: There are significant differences in obstetric and psychosocial risk profiles and maternal and neonatal outcomes between Australian-born and non-Australian born women. In particular there appears to be an association between an EPDS of ≥13 and developing GDM, which warrants further investigation