The assessment and management of risk in order to promote safe childbirth are inherent amongst all medical care providers supporting birth. (Skinner & Dahlen 2015) The concept of risk and the definition of safety in birth are a complex and sometimes paradoxical discussion which is strongly influenced by the perception and bias of the discusser. For confinement of such a vast topic, this essay will firstly outline a midwifery-led approach to birth and the challenge midwives face to practice in accordance with their regulating boards in the current model of care most Australian women are accessing. (Australian Institute of Health and Welfare 2016) This essay will then discuss how risk influences birth setting availability, the choice to intervene in physiology from both a midwifery and obstetric view, the risk posed to the emotional and mental wellbeing of women and lastly, how birth as a medical event impacts culturally on women birthing in remote Australia.
Risk is an accepted part of healthcare (Medical Board of Australia 2014). While the number of perinatal and maternal deaths have remained low and largely unchanged for at least the last 20 years, birth related deaths do still occur (Australian Institute of Health and Welfare 2016). Skinner & Dahlen (2015) believe it is unrealistic to eliminate all birth risk, despite the current risk adverse birthing culture we are currently facing and many women having the impression that obstetric intervention is not only the safest way to give birth, but can also achieve the impossible.
Midwives are advocates of normal childbirth (International Confederation of Midwives 2014), but are often unable to practice their full scope and therefore support women to achieve normal birth, due to the majority of women’s care and education occurring in medicalised clinical environments. Midwives work in partnership with women, focusing on individual health needs, expectations and aspirations and providing impartial and accurate information to facilitate informed decision making. (Nursing and Midwifery Board of Australia 2008) The International Confederation of Midwives (2002) states that health care during birth should include the cultural and emotional needs of the birthing mother and places the mother as the primary decision maker, working in partnership with her care providers.
In Australia, the model of care most women have access to is public care in a hospital-based setting and is usually inclusive of induced, augmented, instrumental or caesarean births which account for 80% of recorded births. (Australian Institute of Health and Welfare 2016) Obstetric perspective of risk influences how these maternity services are governed. (Healy, Humphreys & Kennedy 2016) The belief that birth is abnormal and safest if treated as a medical event, along with the fear of involvement in adverse outcomes is resulting in rising intervention rates for low-risk women. As intervention increases, so too are morbidity rates related to intervention itself (Healy, Humphreys & Kennedy 2017). Olsen and Clausen (2012) agree that hospital-based birth settings are related to unnecessary intervention and complications purely from exposure to the medical system. We see these high rates of intervention reflected in the data, with only 20% of women in Australia experiencing a physiological birth. (Australian Institute of Health and Welfare 2016) Health care that is service-centred and risk adverse rather than being woman-centred promotes this medicalisation of birth. (International Confederation of Midwives 2002)
The International Confederation of Midwives (2005) states that it is imperative to avoid unnecessary interference in the progress of physiological birth, which is a normal process for most women. Birth requires a health-orientated approach in which intervention is only appropriate when there is a clear and present danger to the health of the woman or her baby that can reduced or eliminated through evidence-based technological interventions. This decision to use or not use technology in childbirth is the woman’s to make, and requires true and complete informed consent.
Conversely, The Royal Australian and New Zealand College of Obstetrics and Gynaecologists (2010) state that in a case of a physiological birth with no complications, minimal intervention is required and that even low-risk women can rapidly develop complications and therefore must have timely access to medical interventions. An example of such intervention could be the undertaking of instrumental birth which is quite a common practice in Australia, with 19% of vaginal births being assisted by either vacuum or forceps delivery (Australian Institute of Health and Welfare 2016). The Royal Australian and New Zealand College of Obstetrics and Gynaecologists (2016) says that instrumental birth is employed to accelerate birth when indicated, and is a safe option in select cases. They also acknowledge that instrumental birth is associated with fear of subsequent birth and post-traumatic stress-type syndrome and maternal and neonatal morbidity including shoulder dystocia, subaponeurotic/subgaleal haemorrhage, facial nerve palsy, corneal abrasion, retinal haemorrhage, skull fracture and/or intracranial haemorrhage, cervical spine injury and other maternal complications including vaginal trauma, third or fourth degree tears of the anal sphincter, postpartum haemorrhage, urinary tract injury, and damage to pelvic floor and anal sphincter. Despite these risks there are few absolute indications for instrumental birth. (The Royal Australian and New Zealand College of Obstetrics and Gynaecologists 2016). Such indications as diagnosed at the discretion of the medical provider include suspected or anticipated fetal compromise, delay in the second stage of labour, failure to progress or when maternal effort is contraindicated. Medical professionals are encouraged to apply case-by-case clinical decision-making based on the best and most relevant evidence available. (The Royal Australian and New Zealand College of Obstetrics and Gynaecologists 2016)
33% of Australian mothers birth via Caesarean delivery which includes both elective procedures and emergencies. (Australian Institute of Health and Welfare 2016) The International Confederation of Midwives (2002) believes this increasing rate of Caesarean section is related to the threat of litigation, being service-oriented or meeting social needs rather than the need to change practice due to new evidence around prevention of maternal or perinatal morbidity or mortality. The Royal Australian and New Zealand College of Obstetrics and Gynaecologists (2016) says that Caesaren section is a safe procedure but also states (2010) that this method of delivery is associated with significantly increased risk of maternal morbidity, including haemorrhage, bladder trauma and requirement for intensive care, as well as complications in subsequent pregnancies such as ectopic pregnancy, preterm birth, unexplained stillbirth after 34 weeks and uterine scar rupture. There is also a negative association between caesarean delivery and early breastfeeding. Interestingly, Figueiredo, Canario & Field (2014) demonstrated that incidence and severity of depression was significantly decreased in women who maintained exclusive breastfeeding for 3 months or more after birth.
Bastos et al. (2015) state that traumatic birth experiences have a negative impact on a woman’s emotional wellbeing postnatally. The Royal Australian and New Zealand College of Obstetrics and Gynaecologists (2015) state that up to 80% of mothers experience the ‘baby blues’ and 16% go on to experience anxiety or depression postnatally. 2-3% of women also experience post-traumatic stress disorder after childbirth. They acknowledge that the psychological wellbeing of pregnant women and new mothers should be considered of the same importance as their physical wellbeing. Many women are seeking alternative pain management techniques which improve their ability to cope and feel relaxed during labour, such as the use of water immersion. (Cluett & Burns 2009) The Royal Australian and New Zealand College of Obstetrics and Gynaecologists (2014) do not recommend or support water-birth as obstetric and neonatal emergencies cannot be adequately managed. They also believe there is an increased risk of water aspiration, neonatal and maternal infection and negative associations with neonatal and maternal thermo-regulation. Cluett & Burns (2009) say that there is no evidence of increased adverse affects to the mother or baby from labouring or delivering in water. Young & Kruske (2013) say that women have been birthing in water for many years backed by research of a number of benefits to mother and baby with no evidence-based findings to back any clinical concerns. They recommend that all women have access to this method of birth if chosen.
Women are increasingly seeking alternative birth settings and models of care for a variety of reasons, including wanting a non-medicalised approach to birth and the associated positive birth outcomes with reduced rates of birth related trauma. (Dahlen, Jackson & Stevens 2011) Davis et al. (2011) demonstrated that where a woman planned to give birth had a significant influence on her birth outcome and the rate of intervention she received. Dhalen et al. (2012) mimicked these findings demonstrating that low-risk primiparous women giving birth in a private hospital under obstetric care were more likely to have a surgical birth than if they were in a public hospital, and this had increased substantially in the last decade. Associatively, Dhalen et al. (2013) say that neonates born in private hospitals are more likely to have higher rates of morbidity than if they were born in a public hospital. Albers & Katz (1991) show that nontraditional birth settings present several other advantages for low-risk women as compared with traditional hospital settings including lower maternity care costs without significant differences in perinatal mortality.
The Royal Australian and New Zealand College of Obstetrics and Gynaecologists (2014) do not endorse alternative models of care, such as home birth, which they report are associated with unacceptably high rates of adverse outcomes. This belief is evidenced in our legislative system, as currently there is no insurance cover for intrapartum care for a planned home birth in Australia. (Medical Insurance Group Australia 2016) Conversely, Olsen and Clausen (2012) say that hospital-based birth settings are not any safer than planned home birth settings with an experienced midwife. Sandall et al. (2016) also demonstrate that women who received continuity of care in a midwife-led model, such as caseload midwifery or private practice midwifery, had better birth outcomes, were more likely to experience physiological birth and had at least comparable adverse outcomes for themselves and their babies to other models of care. The rise of women free birthing or hiring a doula is indicative of this growing trend that women feel less at risk birthing alone than they do in our current medical system. (Dahlen, Jackson & Stevens 2011) The International Confederation of Midwives (2011) supports women to choose a home birth as a valid and safe option and believe midwives who provide a home birth service should have access to the public health system, appropriate insurance and compensation.
Birth as a medical event combined with our risk adverse culture also has significant cultural implications for birthing women. (Skinner & Dahlen 2015 pp. 88-93) Women in rural and remote areas of Australia have higher neonatal and maternal rates of morbidity and mortality than their urban neighbours. (Kildea, Kruske & Sherwood 2016 pp. 208-211) Underpinning this is both geographical access to advanced obstetric care along with increasing risk rates amongst mothers, and social-historical factors including colonisation, genocide, oppression, social exclusion, Western-informed healthcare, loss of land and people and devaluing Aboriginal knowledge. Aboriginal women in remote parts of Australia are required to leave their communities and families and travel alone to major cities for the birth of their babies in a hospital setting. (Byers 2016) There are several cultural, social and economical issues for these women, who very often do not want to leave their families and birth outside of their culture. (Watsonet al. 2002)
The Maternity Services Plan highlights the need to close the gap in health outcomes for Indigenous and Aboriginal women, including providing culturally appropriate birthing options. (The Department of Health 2010) In traditional Aboriginal culture birth is a spiritual and sacred event deeply connected to the land. (Remote Primary Health Care Manuals 2014) Women who live in Alice Springs or Darwin in close proximity to major hospitals are permitted to birth at home, as long as they meet certain criteria that deems them as low-risk, however women outside of these areas do not have access to these culturally appropriate options. (Northern Territory Government 2016) Aboriginal mothers are statistically more likely to deliver vaginally and less likely to receive intervention during delivery than non-Aboriginal mothers. (Comino et. al 2011) Currently it is estimated that only half of Aboriginal women attend antenatal care in the first trimester and are less likely to attend 5 of more total antenatal appointments than non-indigenous women (Australian Institute of Health and Welfare 2016) It has been recognised that caseload midwifery models with Aboriginal and Torres Strait Islander midwives in remote communities across Australia are needed in order to increase uptake of culturally safe antenatal care for Aboriginal women for better health outcomes. (Kelly et al. 2014)
The concept of risk has complex and sometimes paradoxical influences on how maternity care is offered in Australia. Perception of risk is largely determined by the education, experience and bias of the viewpoint being considered and the desired outcome. Most Australian women receive maternity care in a public hospital-based model which is largely influenced by obstetric view of risk with the associated high rates of intervention and caesarean delivery. Midwives are advocates for normal birth and work within a woman-centred framework, but are often unable to practice to their full scope within this medicalised system to support women to achieve normal birth. Midwives believe that birth should be allowed to progress physiologically unless there is a clear and immediate threat to the mother or baby. A medical approach to birth assumes that birth is a medical event safest managed by technology, and therefore interventions are appropriate at the physicians discretion with loose and unspecific guidelines for their use. Many interventions are traumatic and may result in increased morbidity and mortality for both the mother and baby, including lower breastfeeding rates and adverse outcomes for maternal mental and emotional health postnatally. Women are limited in where they can choose to give birth by financial, legislative and social factors. Home-birth and water-birth are two alternative care options that are evidence-based but shunned by our current medical system due to litigation and delay or inability to perform obstetric interventions. Aboriginal or Indigenous women in remote communities are not supported to birth in a culturally safe way, resulting in low rates of antenatal care attendance and women being evacuated to major hospitals to give birth alone and without the cultural support and spiritual significance that they would have traditionally received if they were supported to birth on country. Approaching birth as a medical service, rather than a significant life event for the woman, her family and the community does not lower risk of morbidity or mortality, and may actually increase it.
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