Australian women's perception of their preparation for and actual experience of a recent scheduled caesarean birth

What do women in Australia want from their maternity care: A scoping review

BACKGROUND

Just over 300,000 women give birth in Australia each year. It is important for health care providers, managers, and policy makers know what women want from their care so services can be provided appropriately. This review is a part of the Midwifery Futures Project, which aims to prepare the midwifery workforce to best address the needs of women. The aim of this review was to describe and analyse current literature on the maternity care needs of women in Australia.

METHODS

A scoping review methodology was used, guided by the Joanna Briggs Institute framework. A systematic search of the literature identified 9023 studies, and 59 met inclusion criteria: being peer-reviewed research focusing on maternity care needs, conducted in Australian populations, from 2012 to 2023. The studies were analysed using inductive content analysis.

RESULTS

Four themes were developed: Continuity of care, being seen and heard, being safe, and being enabled. Continuity of care, especially a desire for midwifery continuity of care, was the central theme, as it was a tool supporting women to be seen and heard, safe, and enabled.

CONCLUSION

This review highlights that women in Australia consistently want access to midwifery continuity of care as an enabler for addressing their maternity care needs. Transforming Australian maternity care policy and service provision towards continuity would better meet women's needs.

In what ways does maternity care in Australia align with the values and principles of the national maternity strategy? A scoping review

Australia's national maternity strategy Woman-centred care: strategic directions for Australian maternity services (the Strategy) was released by the federal government in November 2019. It was developed to provide national guidance on the effective provision of woman-centred maternity care. The Strategy is structured around four values of safety, respect, choice, and access, and underpinned by twelve principles of woman-centred care. By examining previous research, this review aims to provide a baseline understanding of how maternity care provision is being met in relation to these core values. A systematic search of Australian literature was undertaken via four databases using the Strategy's values and 41 articles met the selection criteria. Include articles were predominantly published pre-2019, providing a baseline understanding of Australian maternity care provision prior to the Strategy's publication. Findings suggest that the four values align with those of women; however, women were not always receiving care in accordance with the values, particularly among women from priority populations. Women prioritised safety for themselves and their babies, articulated the need for respectful relationships with maternity care providers, wanted autonomy to make their own decisions, and desired access to appropriate, local, maternity services. Additionally, while pockets of appropriate care do exist, these are more likely to occur at a single-service level than more broadly at a population level. This implies the Strategy is needed, and its operationalisation must be prioritised through a coordinated national response to better meet the maternity care needs of Australian women. Further research is warranted to determine the Strategy's effectiveness.

Using a scheduled caesarean birth plan: A cross-sectional exploration of women's perspectives

PROBLEM

There is minimal evidence regarding the role or impact of birth plans from the perspective of women experiencing scheduled caesarean birth.

BACKGROUND

Quality maternity care requires respect for women's preferences. Evidence suggests birth plans enable communication of women's preferences and may enhance agency when vaginal birth is intended, however there is limited evidence of how this translates in the perioperative environment where caesarean birth is the intended outcome.

AIM

Explore the experiences and perspectives of women who had utilised a scheduled caesarean birth plan at an Australian tertiary maternity hospital.

METHODS

A cross-sectional design was used; 294 participants completed the survey within two weeks post-birth. Descriptive statistics were used to analyse quantitative data, qualitative responses were analysed using content analysis.

FINDINGS

Over half of the women requested lowering of the surgical-screen at birth, most requested immediate skin-to-skin with their babies; around two-thirds of these preferences were met. Use of a birth plan for scheduled caesarean section supported women's ability to communicate their desires and choices, enhancing agency and reinforcing the significance of the caesarean birth experience. Qualitative data revealed two main categories: Perceptions and experiences; and Recommendations for improvement, with corresponding sub-categories.

DISCUSSION

Findings provide unique opportunities to consider the provision of woman-centred care within the highly technocratic perioperative environment.

CONCLUSION

All women, regardless of birth mode, have a right to respectful maternity care that prioritises their wishes and agency. This study provides evidence for the positive utility of birth plans in caesarean birth, local adaptation is encouraged.

What are women's experiences of immediate skin-to-skin contact at caesarean section birth? An integrative literature review

BACKGROUND

Skin-to-skin is a well-established practice at vaginal births promoting the health of women and babies. Facilitation of skin-to-skin at caesarean section birth is growing despite environmental and historical challenges. This is led by the expectancy of women and of health professionals increasingly understanding its importance.

OBJECTIVE

To synthesise original research that explores the experience of women having immediate and uninterrupted skin-to-skin contact at caesarean section when woman and baby are well.

DESIGN

Integrative literature review.

DATA SOURCES

The databases of SCOPUS, PubMed, CINAHL plus, Wiley Online, Cochrane Library, Web of Science and MIDIRS were used to identify studies from 2010-2020. Hand searching of library journals, reference and citation lists were also used.

METHODS

The framework of Whittemore and Knafl (2005) was used to guide the literature search, thematic analysis, and synthesis of original research. Initial screening against inclusion criteria was utilised for English-published papers of full-term, well, woman and baby dyads who experienced skin-to-skin at caesarean section birth. Papers were not limited by methodology. The validated Mixed Methods Appraisal Tool (MMAT) was used for critical quality appraisal (Bartlett et al., 2018).

FINDINGS

In total, 750 results were returned in the initial search and a final 13 papers were included in this review including quantitative (6), qualitative (5) and mixed method (2) designs. Immediate and uninterrupted skin-to-skin at caesarean section birth, when mother and baby are well, is safe, appropriate and desired by women, improving birth experience and satisfaction. Three main themes were identified with sub-themes - Positive birth experience (satisfaction; breastfeeding goals); Sense of control (empowered; birth, not a procedure); Natural (wanting to hold their baby; becoming a mother).

CONCLUSIONS

The findings of this review show that skin-to-skin improves the experience for women, and particularly empowers women having a caesarean section giving them a sense of a more natural birth. Women see skin-to-skin as an opportunity to maintain control and not be separated from their baby. Many studies have focused on the benefits of skin-to-skin but less so on the wants and choices of women. Women want to see, hold and feed their babies but are unable to achieve this of their own volition during a surgical birth. Understanding how women value this close physical contact can seek to inform further research on the impact of separation. This can inform policy and practice development in maternity care services to ensure best outcomes for both women and infants.

IMPLICATIONS FOR PRACTICE

The practice of skin-to-skin and keeping mother and baby together is valued by women and justified by research as best-practice for health and well-being. The findings of this paper highlight the importance of maternity settings facilitating both skin-to-skin and non-separation for all women and their newborns, even more so at caesarean section births.

Parents' experiences of early discharge after a planned caesarean section: A qualitative interpretive study

OBJECTIVE

The birth rate in Denmark is increasing, and the rate of births by caesarean section has increased to more than 20%. Thus, the obstetric departments have been put under pressure to identify new solutions to optimize the maternity care system, in which early discharge might be considered. The aim of this study was to explore parents' experiences of the postnatal care after planned caesarean section with focus on factors that support or hinder early discharge.

DESIGN

An interpretive, hermeneutic approach was chosen, using qualitative interviews with multiparous women and their partners. Data analysis was performed using thematic analysis.

PARTICIPANTS AND SETTING

Twelve women and partners were recruited from two hospital-based maternity units in Denmark. The inclusion criteria were low-risk Danish-speaking multiparous women having a planned caesarean section with a singleton pregnancy (gestational age between 37+0 and 41+6 weeks). Seven sets of parents were discharged before 28 h and five were discharged after 48 h.

FINDINGS

Three main themes were identified as important for timing of discharge: (1) Setting for recovery (2) Views on length of stay, and (3) Preparation and individual planning. All parents valued the safe and supportive environment at the hospital, but several preferred early discharge as they felt more comfortable in their home environment and wanted to be together as a family with all siblings. When considering appropriate time of discharge, the main issues were that pain was manageable, that breastfeeding was initiated successfully and that professional support was available after discharge. Finally, early discharge required preparation and planning and the parents stressed the importance of knowing that they would not be discharged unless they felt ready.

CONCLUSION AND IMPLICATION FOR PRACTICE

A clear link was observed between the care package the parents received and their views on the optimal time of discharge. Based on our findings it seems likely that a significant proportion of parents will accept and feel confident about early discharge if individual circumstances are taken into account in the antenatal planning of a caesarean section.

Plans, preferences or going with the flow: An online exploration of women's views and experiences of birth plans

OBJECTIVE

To explore women's views of birth plans, and experiences of their completion and use.

DESIGN

A qualitative, descriptive study, using Internet-mediated research methods.

SETTING

The discussion boards of two well-known, UK-based, online parenting forums, where a series of questions relating to birth plans were posted.

PARTICIPANTS

Members of the selected parenting forums who had written and used, or who had chosen not to write or use, a birth plan.

FINDINGS

Women responded with a range of views and experiences relating to the completion and use of birth plans. The benefits of birth plans were described in terms of communication with healthcare professionals, potentially enhancing awareness of available options, and maintaining a sense of control during labour and birth. However, many respondents believed the idea of 'planning' birth was problematic, and described a reluctance to write a formal plan. The support of healthcare professionals, particularly midwives, was considered essential to the success of both writing and using birth plans.

KEY CONCLUSIONS

Our findings show a continued debate among women on the benefits and challenges involved in writing and using birth plans, suggesting problems for a 'one size fits all' approach often seen in the use of birth plan templates. In the context of maternity policy supporting women's choice and personalised care, and as a way of acknowledging perceived problems of 'planning' for birth, a flexible approach to birth plans is required, including the consideration of employing alternative nomenclature.

IMPLICATIONS FOR PRACTICE

Birth plans remain a point of contention in care contexts around the world. Midwives and other healthcare providers play a central role in supporting women to discuss available options, whether or not they decide to complete a formal birth plan.

Object relations, unconscious defences and fear of childbirth, as reflected in maternal-request caesarean section

OBJECTIVE

To examine a possible association between maternal-request caesarean section (CS) and two intrapsychic psychoanalytic personality variables: object relations (OR) and unconscious defences.

BACKGROUND

While maternal-request CS is a growing phenomenon, studies are lacking regarding personality variables that may be associated with it.

METHODS

A cross-sectional questionnaire was conducted in one delivery ward. During 2009, 59 primigravida, healthy women were recruited; 28 who had requested and delivered by CS without an obstetrical indication and 31 who opted for a spontaneous vaginal delivery. Due to missing data for some measures, only 27 participants were analysed in each group. All women completed the fear of childbirth (FOC) questionnaire, and the object relations (SCORS) and unconscious defences (DMM) measures of the Thematic Apperception Test (TAT), as well as questionnaires assessing background variables. Multivariate analysis of variance (MANOVA) and a logistic hierarchical multiple regression were performed.

RESULTS

Preliminary MANOVA showed significant differences between groups in age, FOC and use of the defence mechanism projection. Hence, these variables entered as predictors of maternal-request CS to a logistic hierarchical multiple regression model. The model was found to have a good fit [χ²₍₄₎ = 38.19, p < 0.001]. Age, FOC and projection defence were found to be significant factors associated with maternal-request CS.

CONCLUSION

Maternal-request CS was found to be strongly associated with age and FOC. Except for unconscious defence of projection, intrapsychic variables were not found to be associated with maternal-request CS. Possible implications are discussed.

Gaining insight into how women conceptualize satisfaction: Western Australian women's perception of their maternity care experiences

Background

The concept of maternal satisfaction is challenging, as women’s and clinicians’ expectations and experiences can differ. Our aim was to investigate women’s experiences of maternity care in an urban tertiary obstetric setting, to gain insight into conceptualization of satisfaction across the childbirth continuum.

Methods

This mixed method study was conducted at a public maternity hospital in Western Australia. A questionnaire was sent to 733 women two weeks post birth, which included an invitation for an audio-recorded, telephone interview. Frequency distributions and univariate comparisons were employed for quantitative data. Thematic analysis of interview transcripts was undertaken to extract common themes.

Results

A total of 54 % (399 of 733) returned the questionnaire. Quantitative results indicated that women were less likely to feel: involved if they did not have a spontaneous vaginal birth (P = 0.020); supported by a midwife if they had a caesarean (P = <0.001); or supported by an obstetrician if they had a spontaneous vaginal birth (P = <0.001).

Qualitative findings emerged from 63 interviews which highlighted the influence that organization of care, resources and facilities had on women’s satisfaction. These paradigms unfolded as three broad themes constructed by four sub-themes, each illustrating a dichotomy of experiences. The first theme ‘how care was provided’ encompassed: familiar faces versus a different one every time and the best place to be as opposed to so disappointed. The second theme ‘attributes of staff’ included: above and beyond versus caring without caring and in good hands as opposed to handled incorrectly. The third theme ‘engaged in care’ incorporated: explained everything versus did not know why and had a choice as opposed to did not listen to my needs.

Conclusions

Quantitative analysis confirmed that the majority of women surveyed were satisfied. Mode of birth influenced women’s perception of being involved with their birth. Being able to explore the diversity of women’s experiences in relation to satisfaction with their maternity care in an urban, tertiary obstetric setting has offered greater insight into what women value: a sensitive, respectful, shared relationship with competent clinicians who recognise and strive to provide woman focused care across the childbirth continuum.

Birth Plans: A Narrative Review of the Literature

OBJECTIVE: To describe and summarize the current body of evidence on the subject of birth plans to develop a research agenda.

METHOD: A narrative review was undertaken to offer a comprehensive overview of themes emerging from previous research in this area.

FINDINGS: Thirty-five papers from 33 studies were retrieved and grouped into three main themes: the impact of birth plans on obstetric outcomes, women’s experiences and opinions of completing and using birth plans, and health care professionals’ beliefs about and experiences of the use of birth plans. Key findings relate to beliefs about the benefits and challenges of birth plans, as described by women and health care professionals and the impact of birth plans on a range of obstetric outcomes.

CONCLUSION: This review brings together a range of studies around birth plans and synthesizes key themes. Little homogeneity was seen in the studies identified, and a wide variety of care contexts and childbirth philosophies were represented. Findings suggest the need for further research into whether there are ideal circumstances and environments for the completion of birth plans antenatally and whether disparities between expectations described in women’s plans and experiences in labor and birth can be reduced.