Women's experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia

Background: Vaginal birth after caesarean (VBAC) is a safe mode of birth for most women but internationally VBAC rates remain low. In Australia women planning a VBAC may experience different models of care including continuity of care (CoC). There are a limited number of studies exploring the impact and influence of CoC on women’s experiences of planning a VBAC. Continuity of care (CoC) with a midwife has been found to increase spontaneous vaginal birth and decrease some interventions. Women planning a VBAC prefer and benefit from CoC with a known care provider. This study aimed to explore the influence, and impact, of continuity of care on women’s experiences when planning a VBAC in Australia. Methods: The Australian VBAC survey was designed and distributed via social media. Outcomes and experiences of women who had planned a VBAC in the past 5 years were compared by model of care. Standard fragmented maternity care was compared to continuity of care with a midwife or doctor. Results: In total, 490 women completed the survey and respondents came from every State and Territory in Australia. Women who had CoC with a midwife were more likely to feel in control of their decision making and feel their health care provider positively supported their decision to have a VBAC. Women who had CoC with a midwife were more likely to have been active in labour, experience water immersion and have an upright birthing position. Women who received fragmented care experienced lower autonomy and lower respect compared to CoC. Conclusion: This study recruited a non-probability based, self-selected, sample of women using social media. Women found having a VBAC less traumatic than their previous caesarean and women planning a VBAC benefited from CoC models, particularly midwifery continuity of care. Women seeking VBAC are often excluded from these models as they are considered to have risk factors. There needs to be a focus on increasing shared belief and confidence in VBAC across professions and an expansion of midwifery led continuity of care models for women seeking a VBAC

Midwifery care for late termination of pregnancy : integrative review

Midwives provide reproductive healthcare to women, including during termination of pregnancy (TOP) after 12 weeks (late TOP). Their expertise, knowledge and woman-centred care approach sees them ideally placed for this role. However, the medical, social and emotional complexities of late TOP can cause midwives significant distress. An integrative review methodology was used to examine the research on midwifery care for late TOP and identify support strategies and interventions available to midwives in this role. Five databases and reference lists were searched for relevant studies published between 2000 and 2021. A total of 2545 records were identified and 24 research studies included. Synthesis of research findings resulted in three themes: Positive aspects, negative aspects and carers need care. Midwives reported a high level of job satisfaction when caring for women during late TOP. Learning new skills and overcoming challenges were positive aspects of their work. Yet, midwives felt unprepared to deal with challenging aspects of late TOP care such as the grief and the psychological burden of the role. Caring for the baby with dignity had both positive and negative aspects. Midwives relied predominantly on close colleagues for help and debriefing as they felt poorly supported by management, judged by co-workers and lacked appropriate support to reduce the emotional effects of late TOP care. Midwives need support, although current evidence has not identified the most appropriate and effective strategy to support them in this role

Exploration of barriers to screening for domestic violence in the perinatal period using an ecological framework

Aims: To explore Australian healthcare providers' perspectives on factors that influence disclosure and domestic violence screening through the lens of Heise's (1998) integrated ecological framework. Design: This paper reports the findings that were part of a sequential mixed methods study with survey data informing interview questions. Participants for interviews were recruited after expressing an interest after completing surveys, as well as via snowball sampling. Methods: Semi-structured interviews were undertaken in 2017 with 12 practicing healthcare providers delivering care to women in the perinatal period in Greater Western Sydney, NSW, Australia. Data were analysed using Braun and Clarke's (2006) six-step thematic approach. Findings: The findings were framed within Heise's integrated ecological framework under four main themes. The main themes were ‘Ontogenic: Factors preventing women from disclosing’; ‘Microsystem: Factors preventing healthcare providers from asking’; ‘Exosystem: Organizational structures not conducive to screening’; and ‘Macrosystem: Cultural attitudes and socioeconomic influences affecting screening’. Conclusion: Organizational policies are needed for better systems of reminding healthcare providers to enquire for domestic and family violence and mandating this within their practices. Mandatory domestic and family violence education and training that is suitable for the time constraints and learning needs of the healthcare provider is recommended for all healthcare providers caring for perinatal women. Further research is needed in addressing culturally specific barriers for healthcare providers to enquire about domestic and family violence in a culturally appropriate way. Public and Patient Engagement and Involvement in Research (PPEI): No Patient or Public Contribution was embedded into the research reported in this paper as this research was specifically exploring healthcare providers’ perspectives on domestic violence screening within their own practice experience

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

Perinatal depression in Australian women during the COVID-19 pandemic : the birth in the time of COVID-19 (BITTOC) study

The COVID-19 pandemic has impacted perinatal mental health globally. We determined the maternal factors and pandemic-related experiences associated with clinically significant perinatal (pregnant and post-partum) depressive symptoms in Australian women. Participants (n = 2638; pregnant n = 1219, postnatal n = 1419) completed an online survey (August 2020 through February 2021) and self-reported on depression, social support, and COVID-19 related experiences. We found elevated depressive symptoms amongst 26.5% (pregnant) and 19% (postnatal) women. Multiple logistic regression analyses showed higher likelihood of elevated depression associated with residence in Victoria, lower education, past/current mental health problems, greater non-pandemic prenatal stress, age ≥ 35 years (pregnant women) and existing physical health issues or disability in self or others (postnatal women). Greater family stress/discord and lower social support (friends) was associated with higher odds of elevated perinatal depression, while lower social support (family) was significantly associated with elevated depressive symptoms in pregnant women. Greater depression was associated with social distancing, pandemic-related news exposure and changes to prenatal care (pregnant women). Single postnatal women showed lower odds of elevated depression than partnered women. Our findings underscore the importance of universal screening for depression and targeted support during a pandemic for perinatal women displaying vulnerability factors

Women's reasons for and experiences of having a homebirth following a previous caesarean experience

Background – The rates of caesarean section are rising across the developed world yet the vaginal birth after caesarean (VBAC) rate remains low. Caesarean section is related to increased morbidity for both women and babies, including higher rates of infection, increased need for blood products, operative trauma and neonatal intensive care admissions. Qualitative research suggests that there are women who prefer vaginal births after caesarean if this is supported and dislike unnecessary interventions. VBAC success rates are higher out of hospital than in hospital. A small number of women in Australia choose to have a homebirth after caesarean (HBAC). The reasons women choose to have a HBAC and their experiences have not been explored in research. Aims and methods – This study aimed to explore women's reasons for and experiences of choosing a homebirth following a caesarean section, by undertaking qualitative semi-structured interviews with 12 women who had a HBAC in the previous five years in Australia. A feminist theoretical framework was used to underpin the research and understand the power relations influencing the emerging themes. Eight privately practising midwives (PPMs) participated in a focus group to enhance and provide extra depth and meaning to the study. Thematic analysis was used to analyse the data. Results – The overarching theme was ‘It’s never happening again’ with two associated themes of ‘why it’s never happening again’ and ‘how it’s never happening again’. In the theme ‘why it’s never happening again’ the women described their previous caesarean experience and identified episodes of bullying, intimidation and unnecessary interventions, resulting in what many of the women described as a traumatic birthing experience. With their next pregnancy the majority of women approached the hospital with the wish to have a VBAC but often found bullying and intimidation was repeated with no apparent room for negotiation. In this context, women sought other options and homebirth emerged as a valid one. In the theme ‘How it’s never happening again’, the importance of support from a variety of sources, gaining knowledge about natural birth and employing the services of a PPM emerged as important factors. In this theme women also reported on the positive effect of a HBAC. Discussion – A previous experience of birth trauma, the over-medicalisation of childbirth and disrespectful and abusive attitudes of health care providers were the major influences for women pursuing a more positive birth option and choosing to have a HBAC. Gathering support and the close and continuous relationship with a PPM were factors that helped the women achieve their HBAC. Conclusion – Maternity care services often contribute to women having disempowering and traumatic birthing experiences and some appear to provide little support for women who wish to avoid over-medicalisation. Research is needed to explore ways for maternity providers working in the mainstream maternity care system to become more flexible in their guidelines and approach so they can meet the needs of these women within the hospital environment rather than turning them away. Homebirth can be a healing and empowering experience for women and is a valid option for women seeking a VBAC

A poetic inquiry of traumatic birth through bearing witness

In collaboration between a researcher and poet, we have used poetry inquiry to create a collection of found poems from open-ended survey data. Found poems were created using the written responses from the Australian Birth Experience Study survey and the poems highlighted women’s experiences of traumatic birth. Analysis was undertaken through reflexive poetry from the poet and through reflection by the researcher. The poems display themes of lack of control and consent. These poems illuminate the voices of the women who shared their traumatic birthing stories to gain understanding and raise awareness in the community on aspects of birth trauma

[In Press] Dehumanized, violated, and powerless : an Australian survey of women's experiences of obstetric violence in the past 5 years

Globally, significant numbers of women report obstetric violence (OV) during childbirth. The United Nations has identified OV as gendered violence. OV can be perpetrated by any healthcare professional (HCP) and is impacted by systemic issues such as HCP education, staffing ratios, and lack of access to continuity of care. The current study explored the experiences of OV reported in a national survey in 2021 by Australian women who had a baby in the previous 5 years. A content analysis of 626 open text comments found three main categories: “I felt dehumanised,” “I felt violated,” and “I felt powerless.” Women reported bullying, coercion, non-empathic care, and physical and sexual assault. Disrespect and abuse and non-consented vaginal examinations were the subcategories with the most comments