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How can more women have the experience they want during pregnancy and childbirth?

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How can more women have the experience they want during pregnancy and childbirth?

Globally, Australia is regarded as a safe country for women to give birth.[1] Yet, one in three Australian women emerge from their pregnancy, labour and birth with birth trauma, and one in 10 with post-traumatic stress disorder.[2],[3]

While the physical trauma is often a result of the birthing processes, the psychosocial trauma is linked to episodes of care that fail to respect the choices and preferences of women.[4] For many women, the resultant feeling of disempowerment has detrimental short- and long-term impacts to their sense of self, relationships and parental-infant bonding. This can then influence the child’s social, emotional, and mental development.[5],[6]

It is clear that too often maternity services are failing Australian women and families. It is time to consider how our health system can provide care that respects woman’s rights and improves their experiences.

Better outcomes require care that recognises experiential and medical needs

Pregnancy, birth and postpartum mark a period of significant transition in a person’s life. While at times pregnancy and birth do require medical support neither can be considered a diagnosis or illness, rather they are a normal function of the human body. Yet in Australia, maternity care is delivered largely through a medical model that positions pregnancy and birth as diagnoses to be treated.

Low maternal mortality and morbidity rates demonstrate our health services deliver excellent medical care to Australian birthing women – as they are designed to. However, the reported poor psychological outcomes, distress and trauma rates indicate the system is not adequately meeting the experiential needs of women and their families. Good maternity care sits perfectly at this junction, balancing women’s experiential and medical needs.

Significant progress has been made across Australia to improve the quality of maternity services. The Department of Health’s Woman-centred care: Strategic directions for Australian maternity services[7] provides a framework for further work at national, state, territory and local levels.

But challenges in translating the directions into service delivery models mean Australian birthing mothers have limited access to women-centred care programs. This dynamic is commonly referred to as postcode roulette; a woman’s access to high-quality woman-centred care depends on where she lives, a reality particularly familiar to women from low socio-economic backgrounds and those living in rural and remote locations.

The recent Australia’s Mothers and Babies Report from the Australian Institute of Health and Welfare[8] suggests that women’s access to quality care that balances their experimental and medical needs is getting worse. Intervention rates, which are associated with poorer experience and psychological outcomes and increased cost, are increasing but there is no associated improvement in clinical outcomes. This is a lose-lose situation for women and the system overall.

An example of birthing done well: The Quality Maternal and Newborn Care Framework

Australia’s birth intervention rate is particularly high when assessed against international comparators. For instance, Australia’s caesarean section rate of 36 per cent[9] is much higher than the rate in Iceland, Finland, Sweden and Norway, which have a 15-17 per cent caesarean section rate for all live births (with similar perinatal outcomes).[10] While intervention cannot be used as a direct proxy for good care, international differences in intervention highlight cultural tendencies to provide care in a particular way and suggest there are different ways of providing maternity care that have better outcomes.

In Australia, historically when discussing the quality of maternity care there has been little distinction between what is done, who does it and how it is done.[11] However, variation in intervention and trauma rates across countries and different models of care suggests the what, the who and the how of service delivery play a significant role in meeting the experiences of women in the perinatal period.

The Quality Maternal and Newborn Care (QMNC) Framework focuses on meeting the experiential and medical needs of women and their families.[12] The QMNC identifies and balances the characteristics of care required by women and newborns across five components of the pregnancy and postpartum experience: practice categories, organisation of care, values, philosophy, and care providers.[13]

Under “practice categories”, the Framework suggests quality care requires women to have access to both the promotion of normal process (such as through encouraging mobility in labour and breastfeeding) and first-line management of complications (such as treatment of infection).[14]

Care that aligns to the QMNC has been shown to have positive short-, medium- and long-term outcomes for women and their families, including reduced mortality and morbidity, reduced stillbirth rates, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes.[15]

Involving women in the design of services is key

A fundamental problem is that many of Australia’s maternity services are not yet woman-centred, meaning they do not focus on the psychological, emotional, spiritual and physical needs of women and their families. Instead, services too often prioritise professional preferences and the needs of hospital systems and employees.

Human-centred design (HCD) is well-placed to inform the redesign of services to deliver woman-centred maternity care aligned to the Department of Health’s strategic directions. Through repeated discovery, design and testing, HCD supports the development of services that meet the needs and experiences of users and ensure the delivery of the service’s benefits.

Using HCD to design maternity services has three benefits:

  1. Women-centred services lead to improved health outcomes for women and babies. Women who experience person-centred maternity care have been found to have significantly lower risk of maternal complications, postpartum depression and newborn complications.[16] HCD provides a practical approach to designing person-centred services and can thus support the system to achieve better health outcomes.
  2. Organisational success reflects the needs of users. HCD considers employees, processes and systems to design sustainable maternity services that meet the needs of women. This both allows women to be the centre of service delivery, and services to be delivered within the organisation’s resource constraints. So HCD is perfect for designing services in resource-constrained environments, such as rural and remote Australia. Women-centred services can also help to prevent negative and traumatic birthing experiences that require follow-up care. This means in the long term HCD will create more cost-effective services.
  3. Services promote equity and inclusion. Outcomes for birthing women in Australia vary significantly depending on Aboriginality, remoteness and socio-economic status.[17],[18] HCD focuses on the needs of the people who find services hardest to access, have the worst experiences or get stuck in the system for the longest. As such, HCD ensures all birthing mothers have access to woman-centred services that are culturally safe and readily available.

A focus on implementation is essential to turn the models into reality

Designing women-centred services is the essential first step to improve maternity care services, but implementation in the context of established practice and disparate stakeholder perspectives requires focus and leadership.

Nous’ Seven Levers of Cultural Change promotes a holistic approach to implementing change and developing a positive workplace culture across all elements of a service operating model:

Nous' seven levers of culture change model

The Seven Levers model recognises that conditions for positive culture change are often set top down with change created bottom up. This means change must be driven by empowered leaders at all levels, who can co-create and own the culture strategy. The importance of this is evidenced by a significant and growing body of evidence that links workplace leadership and culture with improved patient experience and health outcomes.[19]

The model embeds the cultural and capability changes required to deliver good care. In isolation, neither a woman-centred model or good workforce culture and leadership will be enough. It is the combination of the two that allows for high-performing teams that can deliver good experiential and medical maternity care to Australian women.

It is time to change

A good birth does not just require access to quality medical services, it also requires women-centred care that empowers women and promotes human rights.

Human-centred design – alongside workplace cultural and leadership development and a focus on implementation – can reform maternity services so Australian women receive the best experiential and medical care possible.

Get in touch to explore how Nous can work with you to help more women have the experience they want during pregnancy and childbirth.

Connect with Ian Thompson and Emily Hull on LinkedIn.

Published on 12 January 2022.

 

[1] Department of Health (2019). Woman-centred care: Strategic directions for Australian maternity services

[2] Creedy D. K., Shochet, M. and Horsfall, J. (2000). Childbirth and the development of acute trauma symptoms: incidence and contributing factors

[3] Simpson, M., Schmied, V., Dickson, C. and Dahlen H.G. (2018). Postnatal post-traumatic stress: An integrative review

[4] Reed, R., Sharman, R. and Inglis, C. (2017). Women’s descriptions of childbirth trauma relating to care provider actions and interactions

[5] Fenech, G. and Thomson, G. (2014). Tormented by ghosts from their past: a meta-synthesis to explore psychosocial implications of a traumatic birth on maternal well-being

[6] O’Hara, M. and McCabe, J. (2013). Postpartum depression: Current Status and Future Directions

[7] Department of Health (2019). Woman-centred care: Strategic directions for Australian maternity services

[8] AIHW (2021). Australia’s mothers and babies

[9] AIHW (2021). Australia’s mothers and babies

[10] OECD (2019). Health at a Glance 2019: OECD Indicators

[11] Symon, A. et al. (2016). Midwifery-led antenatal care models: mapping a systematic review to an evidence-based quality framework to identify key components and characteristics of care

[12] Renfrew, M. et al. (2014). Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care

[13] Renfrew, M. et al. (2014)

[14] Renfrew, M. et al. (2014)

[15] Renfrew, M. et al. (2014)

[16] Sudhinaraset, M. et al (2021). Person-centred maternity care and postnatal health: associations with maternal and newborn health outcomes

[17] Department of Health (2010). National Maternity Services Plan

[18] Rolfe, M. et al. (2017). The distribution of maternity services across rural and remote Australia: does it reflect population need?

[19] See for example Lyubovnikova, J., West, M. A., Dawson, J. F., and Carter, M. R. (2015) 24-Karat or fool’s gold? Consequences of real team and co-acting group membership in healthcare organizations