All women experience emotional changes in relation to being a new parent. Pregnancy and birth are considered significant events that create physiological and behavioural adaptive responses known as emotions 1. There are often unexpected reactions of sadness, self-doubt, guilt, disempowerment, trauma, and loneliness 2,3. This essay will firstly describe how normal bodily changes that result from childbirth may affect the emotional wellbeing of the woman as she makes this transition. It will then use current literature to articulate the midwife’s role in caring for the woman’s psychological health at this time, paying particular attention to evidence on the midwife’s scope of practice, assessment of care needed, normal and abnormal expectations in the postnatal period, including health promotion, and increased risk factors. Lastly, this essay will describe some community resources that the midwife may offer the family to address any queries, concerns, and referral pathways that are needed.
Anatomically a woman’s body changes in pregnancy and childbirth due to the physical changes of the physiological birth process 4. This includes significant breast changes, uterine involution and the body returning towards a pre-pregnant state 4. Depending on her perspectives about body image, these may affect her emotional wellbeing during her transition to parenthood 5,6. Hormonal puerperium changes have an effect on emotional states, namely the decreases in oestrogen and progesterone and an increase in prolactin and oxytocin 4. Changes in neurotransmitters such as serotonin, dopamine and norepinephrine also play a significant role in psychosocial and depressive behaviours 4,7,8.
Within the midwife’s scope of practice, midwives care for and respond to a woman’s emotional state and offer access to needed support 9,10. Some evidence argues that this is an area midwives need to pay more attention to 11, haveing the potential to create an environment that may buffer the negative effects of obstetric complications post birth 12–14. Successful parental transitions have been attributed to the midwife’s ability to connect to women 15 and offer non-judgemental family focussed, consistent care that empowers women 16 built on a relationship of trust and understanding 17. How women are cared for by health professionals impacts how early parenthood is managed and emotional support is vital 18. This relationship is enhanced with continuity of care and being home-based where the woman feels safe, receives more quality time, experiences greater confidence, and a sense of community and cultural acceptance 11,19–21. When this level of support is achieved it strengthens the woman’s self-efficacy, her ability to organise support, and instigate constructive coping strategies 15.
When assessing and prioritising the emotional care that may be provided to the post-natal woman, the midwife should ask the woman herself at each contact about her health and concerns 22. These are often called ‘listening visits’ 23. This may involve allowing a woman to debrief and share her birth experience 13,22,24. Some new mothers feel negatively towards their birth experience with emotions influenced by hormonal fluctuations, fear, depression and violations during labour 25. Others feel empowered, confident and more relaxed about their labour and birth experience 25. Listening involves tuning into the woman’s emotional state, and midwives are in the perfect position to screen for any issues 22,26. Creating these positive experiences should not exclude provision of honest information 27.
The information a midwife offers should be based on evidence and promote emotional health appropriate to that family 9,10,28,29. This includes ensuring the woman is sufficiently informed and reassured about the realistic expectations of the post-natal period 15,24,27. They should inform the family of the new demands of parenthood, including increased mood-disorder and sometimes depression which diminishes self-regulation 30. Woman tend to emotionally regulate to their baby’s distress, their own sleep deprivation, any breastfeeding challenges, and the new family dynamics, so it is therefore important that these situations are anticipated 30. It is also recommended that there is discussion about the devalued postpartum body and the emotional expectations about ‘bouncing back’ 31.
The woman should be informed that between three to seven days postpartum, she may experience what is known as ‘baby blues’ 4. She should be informed that this is a normal transient physiological stage where the adjusting hormones are said to cause tearfulness, mood changes, irritability, forgetfulness, fatigue and some minor stress and anxiety in 50% of mothers 4. Families should also be educated to watch for abnormal signs of continuing emotional disturbances that escalate to post-natal depression (PND) and postpartum psychosis 4. These affect 10% and 3% respectively and include exacerbated sleep and anxiety symptoms as well as reduced self-esteem and weight loss which may escalate to delusions and hallucinations 4.
Included in a midwife’s emotional health promotion of the post-natal period should be some recommendations for a range of supports for this transition as pharmacological and psychotherapeutic therapies may not offer complete solutions 32. Partner, family and social support has a positive impact on maternal wellbeing and reduces depression and anxiety 2 24. So too does religion, infant bonding, forming friendships, education, and utilising childcare 33. It has also been shown that exercise can increase positive feelings 34 and singing to babies can strengthen emotional thoughts towards them 32.
When addressing the emotional care a midwife may provide a post-natal woman and her family, we cannot ignore that one in three women experience post-traumatic stress (PTS) following giving birth 12,13. This may have been brought about by obstetric violence, including spoken humiliation, ignored needs and wishes, invasive or forced medical procedures or interventions, an unwell baby, previous life events, pregnancy trauma and concerns around babies wellbeing 18,25. For 1.7-9% of women, this can develop into post-traumatic stress disorder (PTSD) where there is intense or prolonged psychological distress 35. Both PTS and PTSD symptoms lead to poor maternal health, infant bonding and family relations 35, and should be treated with heightened awareness, extra consistent, non-dismissive, supportive, emotional care to reduce early parenting difficulties 18. Time should be allowed for reflection and validation 18 and a referral should be made if appropriate 22.
Current literature also shows other risk factors for poor mental health that include a caesarean birth 4,18,35,36, pre-existing emotional experiences 4,18,30,35, an unwanted pregnancy 2, separation from family and culture 33, birth complications, low income 4,27, relationship issues, poor social and emotional support, and the death of baby 4. Particular attention would need to be considered in these situations when a midwife is assessing the level and content of care to provide.
Some helpful community resources that a midwife could suggest would be to consult the woman’s General Practitioner with any issues or questions but to also inform her that Victoria has a free Maternal and Child Health (MCH) Service that is focused on the health outcomes for children and families including maternal emotional factors 3. A visit from an MCH nurse is scheduled in their home within two weeks of birth and in-clinic support is offered until the child is school age. The MCH service is guided by the ‘Perinatal mental health and psychosocial assessment’ 37 and includes using the Edinburgh Postnatal Depression Scale (EPDS) screening tool. This tool is used to improve the detection of postnatal depression and is part of the COPE best practice guidelines.
The Centre of Perinatal Excellence (COPE) is a national not-for-profit organisation focused on reducing the effects of emotional and mental health problems in the perinatal periods. Their website is easy to navigate and includes many areas of evidence-based support for women and families. COPE have been working with governments and professional bodies since they transitioned from Beyond Blue in 2013. Beyond Blue focuses on anxiety and depression but in a much broader context. They have specific pregnancy and postnatal information and checks. Perinatal Anxiety and Depression Australia (PANDA) is a more specific organisation supporting recovery from perinatal anxiety and depression for individuals and families. Many of the organisations have ‘hotlines’ and have been listed in the resource list Appendix A.
In conclusion, when reviewing the literature, we can see that not only do normal physiological changes affect the emotional wellbeing of the woman as she makes this transition to motherhood, but that there are many other factors that need to be considered within a midwife’s scope of practice to offer evidence-based support. This essay covered the assessment needed for care and the normal and abnormal expectations in the postpartum period. It included health promotion solutions and some of the increased risk factors for psychological illness. Lastly, it described some community resources that the midwife may offer the family to address any queries, concerns, and referral pathways that may be needed.
(1) James, W. II.—WHAT IS AN EMOTION ? Mind 1884, os-IX (34), 188–205. https://doi.org/10.1093/mind/os-IX.34.188.
(2) Abdollahpour, S.; Keramat, A. The Relationship between Perceived Social Support from Family and Postpartum Empowerment with Maternal Wellbeing in the Postpartum Period. J. Midwifery Reprod. Health 2016, 4 (4). https://doi.org/10.22038/jmrh.2016.7612.
(3) Sanders, R.; Lehmann, J.; Gardner, F. Parents’ Experiences of Victoria’s Maternal and Child Health Service during the Transition to Parenthood. Aust. J. Child Fam. Health Nurs. 2018, 15 (1), 9–16.
(4) Rankin, J. Puerperium—the Mother. In Physiology in childbearing e-book : With anatomy and related bioscience; Elsevier Health Sciences, 2017; pp 592–595.
(5) Prinds, C. Yummy Mummy — The Ideal of Not Looking like a Mother. Women Birth 2020, 8.
(6) Rodgers, R. F. A Biopsychosocial Model of Body Image, Disordered Eating, and Breastfeeding among Postpartum Women. 2018, 6.
(7) Osman, N. N.; Bahri, A. I. Impact of Altered Hormonal and Neurochemical Levels on Depression Symptoms in Women During Pregnancy and Postpartum Period. 2019, 9.
(8) Rihua, X.; Haiyan, X.; Krewski, D.; Guoping, H. Plasma Concentrations of Neurotransmitters and Postpartum Depression. 2017, 8.
(9) International Confederation of Midwives. International Code of Ethics for Midwives https://www.internationalmidwives.org/assets/files/general-files/2019/10/eng-international-code-of-ethics-for-midwives.pdf.
(10) COAG Health Council. Woman-Centred Care: Strategic Directions for Australian Maternity Services. Department of Health August 2019.
(11) Fenwick, J.; Butt, J.; Dhaliwal, S.; Hauck, Y.; Schmied, V. Western Australian Women’s Perceptions of the Style and Quality of Midwifery Postnatal Care in Hospital and at Home. Women Birth 2010, 23 (1), 10–21. https://doi.org/10.1016/j.wombi.2009.06.001.
(12) Baptie, G.; Andrade, J.; Bacon, A. M.; Norman, A. Birth Trauma: The Mediating Effects of Perceived Support. Br. J. Midwifery 2020, 28 (10), 724–730. https://doi.org/10.12968/bjom.2020.28.10.724.
(13) Baxter, J. Postnatal Debriefing: Women’s Need to Talk after Birth. Br. J. Midwifery 2019, 27 (9), 563–571.
(14) Deninotti, J.; Denis, A.; Berdoulat, É. Emergency C-Section, Maternal Satisfaction and Emotion Regulation Strategies: Effects on PTSD and Postpartum Depression Symptoms. J. Reprod. Infant Psychol. 2020, 38 (4), 421–435. https://doi.org/10.1080/02646838.2020.1793308.
(15) Walker, S. B.; Rossi, D. M.; Sander, T. M. Women’s Successful Transition to Motherhood during the Early Postnatal Period: A Qualitative Systematic Review of Postnatal and Midwifery Home Care Literature. Midwifery 2019, 79, 102552. https://doi.org/10.1016/j.midw.2019.102552.
(16) Wiklund, I.; Wiklund, J.; Pettersson, V.; Boström, A.-M. New Parents’ Experience of Information and Sense of Security Related to Postnatal Care: A Systematic Review. Sex. Reprod. Healthc. 2018, 17, 35–42. https://doi.org/10.1016/j.srhc.2018.06.001.
(17) Woodward, B. M.; Zadoroznyj, M.; Benoit, C. Beyond Birth: Women’s Concerns about Post-Birth Care in an Australian Urban Community. Women Birth 2016, 29 (2), 153–159. https://doi.org/10.1016/j.wombi.2015.09.006.
(18) Priddis, H. S.; Keedle, H.; Dahlen, H. The Perfect Storm of Trauma: The Experiences of Women Who Have Experienced Birth Trauma and Subsequently Accessed Residential Parenting Services in Australia. Women Birth 2018, 31(1), 17–24. https://doi.org/10.1016/j.wombi.2017.06.007.
(19) Cummins, A.; Griew, K.; Devonport, C.; Ebbett, W.; Catling, C.; Baird, K. Exploring the Value and Acceptability of an Antenatal and Postnatal Midwifery Continuity of Care Model to Women and Midwives, Using the Quality Maternal Newborn Care Framework. Women Birth 2021, S187151922100041X. https://doi.org/10.1016/j.wombi.2021.03.006.
(20) Forster, D. A.; McKay, H.; Davey, M.-A.; Small, R.; Cullinane, F.; Newton, M.; Powell, R.; McLachlan, H. L. Women’s Views and Experiences of Publicly-Funded Homebirth Programs in Victoria, Australia: A Cross-Sectional Survey. Women Birth 2019, 32 (3), 221–230. https://doi.org/10.1016/j.wombi.2018.07.019.
(21) Forster, D. A.; McLachlan, H. L.; Davey, M.-A.; Biro, M. A.; Farrell, T.; Gold, L.; Flood, M.; Shafiei, T.; Waldenström, U. Continuity of Care by a Primary Midwife (Caseload Midwifery) Increases Women’s Satisfaction with Antenatal, Intrapartum and Postpartum Care: Results from the COSMOS Randomised Controlled Trial. BMC Pregnancy Childbirth 2016, 16 (1), 28. https://doi.org/10.1186/s12884-016-0798-y.
(22) NICE; RCOG. Postnatal Care NICE Guideline. National Institute for Health and Care Excellence April 20, 2021.
(23) Lowenhoff, C.; Appleton, J. V.; Davison-Fischer, J.; Pike, N. NICE Guideline for Antenatal and Postnatal Mental Health: The Health Visitor Role. J. Health Visit. 2017, 5 (6), 290–298. https://doi.org/10.12968/johv.2017.5.6.290.
(24) Slomian, J.; Emonts, P.; Vigneron, L.; Acconcia, A.; Glowacz, F.; Reginster, J. Y.; Oumourgh, M.; Bruyère, O. Identifying Maternal Needs Following Childbirth: A Qualitative Study among Mothers, Fathers and Professionals. BMC Pregnancy Childbirth 2017, 17 (1), 213. https://doi.org/10.1186/s12884-017-1398-1.
(25) Khajehei, M.; Doherty, M. Women’s Experience of Their Sexual Function during Pregnancy and after Childbirth: A Qualitative Survey. Br. J. Midwifery 2018, 26 (5), 318–328.
(26) Moss, K. M.; Reilly, N.; Dobson, A. J.; Loxton, D.; Tooth, L.; Mishra, G. D. How Rates of Perinatal Mental Health Screening in Australia Have Changed over Time and Which Women Are Missing Out. Aust. N. Z. J. Public Health2020, 44 (4), 301–306. https://doi.org/10.1111/1753-6405.12999.
(27) Rizzo, I.; Watsford, C. The Relationship between Disconfirmed Expectations of Motherhood, Depression, and Mother–Infant Attachment in the Postnatal Period. Aust. Psychol. 2020, 55 (6), 686–699. https://doi.org/10.1111/ap.12472.
(28) NMBA. Code of Conduct for Midwives. Nursing and Midwifery Board of Australia. 2018.
(29) NMBA. Midwife Standards for Practice. Nursing and Midwifery Board of Australia. October 1, 2018.
(30) Cao, H.; Zhou, N.; Leerkes, E. M.; Qu, J. Multiple Domains of New Mothers’ Adaptation: Interrelations and Roots in Childhood Maternal Nonsupportive Emotion Socialization. J. Fam. Psychol. 2018, 32 (5), 575–587. https://doi.org/10.1037/fam0000416.
(31) Johnson, S. “I See My Section Scar like a Battle Scar”: The Ongoing Embodied Subjectivity of Maternity. Fem. Psychol. 2018, 28 (4), 470–487. https://doi.org/10.1177/0959353518769920.
(32) Fancourt, D.; Perkins, R. Associations between Singing to Babies and Symptoms of Postnatal Depression, Wellbeing, Self-Esteem and Mother-Infant Bond. Public Health 2017, 145, 149–152. https://doi.org/10.1016/j.puhe.2017.01.016.
(33) Russo, A.; Lewis, B.; Joyce, A.; Crockett, B.; Luchters, S. A Qualitative Exploration of the Emotional Wellbeing and Support Needs of New Mothers from Afghanistan Living in Melbourne, Australia. BMC Pregnancy Childbirth 2015, 15 (1), 197. https://doi.org/10.1186/s12884-015-0631-z.
(34) Hutt, R. L.; Moore, G. A.; Mammen, M. A.; Symons Downs, D. Postpartum Mothers’ Leisure-Time Exercise Behavior Is Linked to Positive Emotion During Partner Discussions. Res. Q. Exerc. Sport 2017, 88 (4), 447–454. https://doi.org/10.1080/02701367.2017.1375450.
(35) Simpson, M.; Schmied, V.; Dickson, C.; Dahlen, H. G. Postnatal Post-Traumatic Stress: An Integrative Review. Women Birth 2018, 31 (5), 367–379. https://doi.org/10.1016/j.wombi.2017.12.003.
(36) Alderdice, F. Psychosocial Factors That Mediate the Association between Mode of Birth and Maternal Postnatal Adjustment: Findings from a Population-Based Survey. 2019, 13.
(37) Victoria State Government. Perinatal Mental Health and Psychosocial Assessment. Victorian Government 2019.
Emotional Wellbeing Resources
Pregnancy and Post-Natal
COPE - https://www.cope.org.au/
PANDA – 1300 726 306 - https://www.panda.org.au/
Beyond Blue – 1300 22 4636 - https://www.beyondblue.org.au/
SANE Australia - 1800 18 7263
MindSpot Clinic - 1800 61 44
4/28/2021 0 Comments
In this essay I will discuss the impact on individuals of implied racism, overt racism and racial commentary toward Aboriginal and Torres Strait Islander people within my future midwifery workplace. I will discuss the differences and offer specific examples and evidence to support the discussion. In the given example, Adam Goodes, an Australian Rules footballer, in 2013 was publicly discriminated against for his features which brought about much commentary and discussion about the normalisation of overt and implied racism and how this gets responded to.
Racism is an assumption of natural hierarchy of culturally and characteristically identifiable groups bringing with it bias and prejudice 1. The ‘lesser’ groups are avoidably and unfairly treated differently 2. Within Australia, these groups are protected by the Racial Discrimination Act of 1975 3 and when the football fan publicly labelled Adam an ‘ape’, this violated this act.
This public name calling can be categorised as overt or explicit racism where the discriminatory behaviour is clear, conscious, direct, obvious, undisguised and blatant and can manifest in physical violence, unfair treatment and insults 4. Overt racism can intentionally be self-monitored to consciously avoid appearing racist 5.
This form of racism has also been called ‘old fashioned’ 6 but over time, legal sanctions have inadvertently created a more subtle form of ‘modern’, implied, implicit, racism that is much harder to detect, label and therefore call out 2. This more covert racism can be found where individuals or organisations behave on the basis of prejudice and stereotypes automatically, unintentionally and unconsciously 7,8.
This implied racism can be seen in the relentless ‘booing’ of Mr Goodes, from many different football clubs until his retirement. This reaction appearing outside of normal fan barracking and jeering behaviour. There is an underlying acceptance of discrimination against this man’s heritage and a lack of acknowledgement of the historical cultural oppression. This ‘booing;’ and the responses in the media and social media in responses to the acts of racism are called racial commentary and have the ability to exacerbate any discrimination but also magnify the need for reform.
Racism also remains very active across the health sector and midwifery workplace 9 with over 70% of surveyed midwives admitting that some staff were disrespectful and racist to indigenous colleagues in their workplace including stereotyping, discrimination and prejudice 10. Ninety nine percent also agreed that racism negatively impacted student outcomes for First Peoples 10. Indigenous midwifes are feeling unsafe and burnt out and not remaining in the workforce 11. There is also evidence of implicit racism that has influenced hiring decisions in the sector 12.
As consumers of health services, First Peoples carry the weight of health inequality 13 and often report experiencing racism 10. Racism causes health inequities and contributes to poor health outcomes experienced by these people 2. Within maternity care, over half of women who identified as Aboriginal, professed experiencing discrimination within their care setting and did not receive care to match their needs 14. These women were more likely to have poor infant health outcomes, including low birthweight and small for gestational age 14.
Examples of this implied racism can be brought about by carer anxiety about working with clients who appear different and include not looking at the women, shortening the consultation or withholding information they would otherwise provide 2. When questioned if they ask all clients if they are an Aboriginal or Torres Strait Islander, midwives replied with “Not if they don’t look it.”, “don’t want to offend someone.” 9. This implies that it is shameful to be Aboriginal.
Not only is this racism seen on an individual level, but there is also outcome disparity within Australian hospitals affected by institutional racism with an organisational change failure rate of 70% 15. On this level we also see a lack of access to care 9 including Aboriginal women not having the ability to honour customs like birthing on country due to lack of an appropriate insurance product to allow midwives to provide evidence based midwifery continuity of care in this setting 16.
Practicing culturally unsafe is racist 2. This includes not listening to or treating a person with dignity and disrespecting their cultural identity 17. Culturally safe maternity care includes an holistic view of a woman’s needs including culture and seeks to reduce any power that may be felt by the women in their care 16. It is important that “only the woman and/or her family can determine whether or not care is culturally safe and respectful” 18
I have defined and discussed the impact on First Nations of implied and overt racism and how racial commentary can affect its effects. I have examined these concepts more comprehensively within my future midwifery workplace, offering specific examples and evidence to support the discussion. As a student and future midwife, I can make a positive contribution to health equity particularly for indigenous Australians by providing care that is culturally safe and respectful.
(1) Hampton, R.; Toombs, M. Racism, Colonisation/Colonialism and Impacts on Indigenous People. In Indigenous Australians and Health : The Wombat in the Room; Oxford University Press, 2013; p 21.
(2) Taylor, K.; Thompson Guerin, P. Determinants of Health. In Health Care and Indigenous Australians : Cultural Safety in Practice : Cultural Safety in Practice; Macmillan Education UK, 2019.
(3) Australian Government. Racial Discrimination Act 1975.
(4) Lui, P. P. Racial Microaggression, Overt Discrimination, and Distress: (In)Direct Associations With Psychological Adjustment. Couns. Psychol. 2020, 48 (4), 551–582. https://doi.org/10.1177/0011000020901714.
(5) Banks, A. J.; Hicks, H. M. Fear and Implicit Racism: Whites’ Support for Voter ID Laws: Fear and Implicit Racism. Polit. Psychol. 2016, 37 (5), 641–658. https://doi.org/10.1111/pops.12292.
(6) Pedersen, A.; Beven, J.; Walker, I.; Griffiths, B. Attitudes toward Indigenous Australians: The Role of Empathy and Guilt. J. Community Appl. Soc. Psychol. 2004, 14 (4), 233–249. https://doi.org/10.1002/casp.771.
(7) Brownstein, M. Implicit Bias https://plato.stanford.edu/archives/fall2019/entries/implicit-bias/.
(8) Quigley, A.; Hutton, J.; Phillips, G.; Dreise, D.; Mason, T.; Garvey, G.; Paradies, Y. Review Article: Implicit Bias towards Aboriginal and Torres Strait Islander Patients within Australian Emergency Departments. Emerg. Med. Australas.2021, 33 (1), 9–18. https://doi.org/10.1111/1742-6723.13691.
(9) Sherwood, J.; Mohamed, J. Racism a Social Determinant of Indigenous Health: Yarning About Cultural Safety and Cultural Competence Strategies to Improve Indigenous Health. In Cultural Competence and the Higher Education Sector; Frawley, J., Russell, G., Sherwood, J., Eds.; Springer Singapore: Singapore, 2020; pp 159–174. https://doi.org/10.1007/978-981-15-5362-2_9.
(10) Fleming, T.; Creedy, D. K.; West, R. Evaluating Awareness of Cultural Safety in the Australian Midwifery Workforce: A Snapshot. Women Birth 2019, 32 (6), 549–557. https://doi.org/10.1016/j.wombi.2018.11.001.
(11) Lai, G.; Taylor, E.; Haigh, M.; Thompson, S. Factors Affecting the Retention of Indigenous Australians in the Health Workforce: A Systematic Review. Int. J. Environ. Res. Public. Health 2018, 15 (5), 914. https://doi.org/10.3390/ijerph15050914.
(12) Ditonto, T. M.; Lau, R. R.; Sears, D. O. AMPing Racial Attitudes: Comparing the Power of Explicit and Implicit Racism Measures in 2008: Comparing 2008 Racism Measures. Polit. Psychol. 2013, 34 (4), 487–510. https://doi.org/10.1111/pops.12013.
(13) CATSINaM; NMBA. NMBA and CATSINaM Joint Statement on Culturally Safe Care. 2018.
(14) Brown, S. J.; Gartland, D.; Weetra, D.; Leane, C.; Francis, T.; Mitchell, A.; Glover, K. Health Care Experiences and Birth Outcomes: Results of an Aboriginal Birth Cohort. Women Birth 2019, 32 (5), 404–411. https://doi.org/10.1016/j.wombi.2019.05.015.
(15) Bourke, C. J.; Marrie, H.; Marrie, A. Transforming Institutional Racism at an Australian Hospital. Aust. Health Rev. 2019, 43 (6), 611. https://doi.org/10.1071/AH18062.
(16) Kildea, S.; Gao, Y.; Hickey, S.; Nelson, C.; Kruske, S.; Carson, A.; Currie, J.; Reynolds, M.; Wilson, K.; Watego, K.; Costello, J.; Roe, Y. Effect of a Birthing on Country Service Redesign on Maternal and Neonatal Health Outcomes for First Nations Australians: A Prospective, Non-Randomised, Interventional Trial. Lancet Glob. Health 2021, S2214109X21000619. https://doi.org/10.1016/S2214-109X(21)00061-9.
(17) Williams, R. Cultural Safety - What Does It Mean for Our Work Practice? Aust. N. Z. J. Public Health 1999, 23(2), 213–214. https://doi.org/10.1111/j.1467-842X.1999.tb01240.x.
(18) Nursing and Midwifery Board of Australia. Code of Conduct for Midwives. Nursing and Midwifery Board of Australia. 2018.
Follow on from '1/9/2021 - LOCAL AND GLOBAL BIRTH TRAUMA AND UN SDG#5'
The United Nation’s (UN’s) Sustainable Development Goal 1 of achieving gender equality and empowering all women and girls is an important goal to focus on in my future midwifery profession as the disparities in maternity care are still to be resolved. In this essay I will identify the challenges to the common good in these disparities. I will then discuss the solutions I feel most relevant to help achieve this goal. I will describe how proposed solutions contribute to the realisation of the common good and what the barriers may be in achieving them.
Gender equality means that women and girls enjoy the same rights, resources, opportunities and protections as men and boys. This is important when addressing the common good of a local and global community. Common good is when the inherent human dignity of each individual within that group is acknowledged and is able to flourish to its full potential 2. It also acknowledges that ‘all human beings are born free and equal in dignity and rights ‘ 3. This includes how woman are treated in childbirth. Woman who have been mistreated in their birth process suffer short and long-term physical and psychological health problems 4. These can have an effect on the infant and future child 5 and affect their capacity to thrive and be an active participant in their community.
When the common good and therefore gender equality are realised, we will see safer, healthier populations 6. Women will birth feeling empowered to make informed, autonomous choices and will be supported through those choices and whatever outcome follows. This is an ideal situation applicable to the local and global maternal environment.
Anecdotal evidence from my local community of public hospitals in Melbourne reflects that women’s birthing processes are far from this ideal. The research tells us that post-traumatic stress rates are as high as 9% for post-natal women 7 and suicide is the third highest cause of maternal deaths in Australia 8. Globally, evidence of the rate of acquiescence and subsequent mistreatment of women in maternity care settings is as high as 40% 9,10.
Those joining the midwifery profession have many ways as individuals and groups to address these poor outcomes. We are front-line providers with substantial reach and have the direct capability to help achieve and sustain the UN’s gender equality development goal 11. I will propose three of these solutions within the local and global environment.
The first is working within a midwifery-led, continuity of care (COC) model and ensuring that woman have access to woman-centred care. This model is where the midwife is the primary carer from the initial maternity appointment, up to six weeks post-partum 12. Within this model a trust relationship can be established, and midwives can offer person specific knowledge, empowering women to make informed, autonomous choices about their care. Women who participate in COC have better healthcare outcomes and higher satisfaction rates 12,13. The partnering relationship empowers women and is endorsed by the International Confederation of Midwives and the Nursing and Midwifery Board of Australia 14,15.
Even with the positive research results concerning this model of supporting woman, it is still only experienced by a very few. Care providers are becoming more specialised and therefore women are more likely to receive fragmented care from different carers 16. This form of fragmented care can be a barrier to establishing a safe, trusting environment where women feel equal and empowered to disclose their thoughts and choices around their care 17.
My second proposal addresses barriers to achieving gender equity in our health system. Decisions relating to women’s care should be facilitated with the inclusion of the community it directly relates to. This is referred to as ‘subsidiarity’ and involves the participation and willingness of people to contribute to the consultation process, while keeping in mind the principle of the common good 18. Involvement may include advisory groups within professional employment, joining and being active with the Australian College of Midwives, offering time to projects with the International Confederation of midwives and getting involved with non-government organisations like Human Rights in Childbirth.
It is imperative to increase the involvement of midwives in policy and decision-making forums on an institutional, national and international level 11. By being a part of larger organisations, we can advocate for health care policy development, planning, and funding that promotes human rights in childbirth and supports gender equity in places where decisions are made. This advocacy gives a voice to those who often do not have the capacity to be heard in a particular setting 19.
A third solution is community engagement. This is an action or process to build relationships with the intention of benefitting the values of a community or group brought together by location, interest, circumstances or vision 20. We can come together as a global family to care for the common good by generating a strong sense of solidarity and connection to offer women a louder voice to address the disparities of those whose rights are extremely compromised. This leads to improved outcomes for communities 21 and stimulates greater international collaboration to attain the UN’s Social Development Goals. Professionals are also able to acquire new skills through mutual learning to bring back to their home environments 11.
There are many maternity care engagements internationally to be involved in, particularly in third world countries where resources are lacking, and where women are often not receiving the needed treatment. These engagements may be ‘on the ground’ clinical support, but we can also utilise our own networks to advocate for these people and promote their needs and procurement of resources to improve women’s chances of flourishing within these populations. Some organisations I have become involved in include Birth For Humankind (Melbourne), Birth Time: the documentary (Australia), Loas Birthwork (Loas) and Bumi Sehat (Indonesia).
Barriers to involvement in decision making and community engagement groups may include accessibility issues by way of location, skills, resources or language. Realising and agreeing on what constitutes the common good may also be a challenge when many ideas are shared in the community, but ‘free societies do not stay free without the involvement of their citizens’ 22. We can however be open to these challenges and create good conditions for relationship, participation, and community 22.
In summary I have examined the gender equity issues for women in my future midwifery profession in my local and the global community. I have addressed how realising the common good is related to achieving the UN’s Sustainable Development Goal of achieving gender equity and empowering all women and girls. I have proposed ways that my professional community can contribute to achieving these goals by working in and advocating for continuity of care models, participating in decision making groups and engaging in community to improve outcomes. As a global midwifery community, we are brought together by focusing on the UN’s goals, but through individual connection to the woman we are working with, we can make these aspirations grow, one woman and baby at a time.
(1) United Nations. Goal 5: Achieve gender equality and empower all women and girls https://www.undp.org/content/undp/en/home/sustainable-development-goals/goal-5-gender-equality.html (accessed Jan 10, 2020).
(2) Part Three: Life in Christ https://www.vatican.va/archive/ccc_css/archive/catechism/p3s1c2a2.htm (accessed Jan 28, 2021).
(3) United Nations. Universal Declaration of Human Rights https://www.un.org/en/universal-declaration-human-rights/index.html (accessed Aug 29, 2020).
(4) Curtin, M.; Savage, E.; Leahy‐Warren, P. Humanisation in Pregnancy and Childbirth: A Concept Analysis. J. Clin. Nurs. 2020, 29 (9–10), 1744–1757. https://doi.org/10.1111/jocn.15152.
(5) Anderson, C. A. The Trauma of Birth. Health Care Women Int. 2017, 38 (10), 999–1010. https://doi.org/10.1080/07399332.2017.1363208.
(6) The benefits of gender equality https://www.vic.gov.au/benefits-gender-equality (accessed Jan 9, 2021).
(7) Simpson, M.; Schmied, V.; Dickson, C.; Dahlen, H. G. Postnatal Post-Traumatic Stress: An Integrative Review. Women Birth 2018, 31 (5), 367–379. https://doi.org/10.1016/j.wombi.2017.12.003.
(8) Australian Institute of Health and Welfare. Maternal Deaths in Australia. 2019. https://doi.org/10.25816/7Q4E-G697.
(9) Bohren, M. A.; Mehrtash, H.; Fawole, B.; Maung, T. M.; Balde, M. D.; Maya, E.; Thwin, S. S.; Aderoba, A. K.; Vogel, J. P.; Irinyenikan, T. A.; Adeyanju, A. O.; Mon, N. O.; Adu-Bonsaffoh, K.; Landoulsi, S.; Guure, C.; Adanu, R.; Diallo, B. A.; Gülmezoglu, A. M.; Soumah, A.-M.; Sall, A. O.; Tunçalp, Ö. How Women Are Treated during Facility-Based Childbirth in Four Countries: A Cross-Sectional Study with Labour Observations and Community-Based Surveys. The Lancet 2019, 394 (10210), 1750–1763. https://doi.org/10.1016/S0140-6736(19)31992-0.
(10) Betron, M. L.; McClair, T. L.; Currie, S.; Banerjee, J. Expanding the Agenda for Addressing Mistreatment in Maternity Care: A Mapping Review and Gender Analysis. Reprod. Health 2018, 15 (1), 143. https://doi.org/10.1186/s12978-018-0584-6.
(11) Rosa, W. E.; Kurth, A. E.; Sullivan-Marx, E.; Shamian, J.; Shaw, H. K.; Wilson, L. L.; Crisp, N. Nursing and Midwifery Advocacy to Lead the United Nations Sustainable Development Agenda. Nurs. Outlook 2019, 67 (6), 628–641. https://doi.org/10.1016/j.outlook.2019.06.013.
(12) Sandall, J.; Soltani, H.; Gates, S.; Shennan, A.; Devane, D. Midwife-Led Continuity Models versus Other Models of Care for Childbearing Women. Cochrane Database Syst. Rev. 2016. https://doi.org/10.1002/14651858.CD004667.pub5.
(13) Jeffers, H.; Baker, M. Continuity of Care: Still Important in Modern-Day General Practice. Br. J. Gen. Pract. 2016, 66 (649), 396–397. https://doi.org/10.3399/bjgp16X686185.
(14) International Confederation of Midwives. International Code of Ethics for Midwives https://www.internationalmidwives.org/assets/files/general-files/2019/10/eng-international-code-of-ethics-for-midwives.pdf.
(15) Nursing and Midwifery Board of Australia. Code of Conduct for Midwives. Nursing and Midwifery Board of Australia. 2018.
(16) Jairath, N.; Donley, R.; Shelton, D.; McMullen, P.; Grandjean, C. Nursing and the Common Good. Soc. Justice Cathol. Health Care 2006, November-December 2006, 59–63.
(17) Viveiros, C. J.; Darling, E. K. Barriers and Facilitators of Accessing Perinatal Mental Health Services: The Perspectives of Women Receiving Continuity of Care Midwifery. Midwifery 2018, 65, 8–15. https://doi.org/10.1016/j.midw.2018.06.018.
(18) Carter, D. What is Subsidiarity? https://leocontent.acu.edu.au/file/5097fe6c-c77e-4787-bfe9-bf98714d060d/21/UNCC100Refresher.html (accessed Jan 28, 2021).
(19) UNCC300 Module 3: Principles of Advocacy. Australian Catholic University 2018.
(20) Moore, T.; McDonald, M.; McHugh-Dillon, H.; West, S. Community Engagement: A Key Strategy for Improving Outcomes for Australian Families. 2016, 39, 25.
(21) Burton, P.; Goodlad, R.; Croft, J. How Would We Know What Works?: Context and Complexity in the Evaluation of Community Involvement. Evaluation 2006, 12 (3), 294–312. https://doi.org/10.1177/1356389006069136.
(22) Mortensen, J. N.; Bech, E. M.; Godrim, F. The Engaged Human: You Are Free for Community. In The Common Good : An Introduction to Personalism; Vernon Press, 2017; pp 57–79.
As a current birth worker and future midwife, I am appalled at the way women are treated in childbirth. The human dignity of this gender in this context seems to be falling short of the United Nation’s (UN’s) Sustainable Development Goal of achieving gender equity and empowering all women and girls. Birth trauma rates are high and the effects on humanity are continually being realised.
The UN’s fifth of seventeen Sustainable Development Goals 1 aims to end gender discrimination, violence and harmful practices, seeking to increase compensation, participation, subsidiarity and solidarity. It aims to strengthen reproductive, economic and technological rights and enforceable legislation for all women, girls and the common good.
The common good is where all members of a community, by virtue of their innate common humanity, can thrive more easily. Acknowledging that gender inequity most commonly disadvantages females calls for extra focus to be placed on the dignity and empowerment of this group. This will ensure that all in the community are remembered and able to reach their full potential 2,3.
Achieving this common good involves modest sacrifices. This could be adjusting the way women are addressed and treated during the epic journey of childbirth. Within maternity units in Melbourne, I see that these measures do not always accomplish these goals.
My local community consists predominantly of publicly funded, high level, teaching hospitals. Within their complicated hierarchy of doctors, midwives and birthing women, there is a strong sense of “power over” dominance 4. Working with families, I witness women struggling to gain autonomy over their bodies and babies. I hear stories of disrespect, abuse and subsequent trauma related to their experience.
A woman’s birth trauma may involve threatened or actual intense fear, helplessness and loss of control during labour and birth, with the perception of her dignity being stripped 5. Dr Amali Lokugamage at the Royal College of Obstetrician and Gynaecologists World Congress takes this treatment a step further and describes this lack of authority and autonomy as "Obstetric Violence" 6.
This form of trauma occurs in birthing settings across the globe. In third world countries, up to 40% of women experience mistreatment in childbirth 7. Women were expected to “obey” rules or else cruelty was deemed justifiable 8. A global analysis showed patterns of normalisation of mistreatment, a "be chaste, be quiet" attitude, woman’s lack of voice about their choices, and insufficient education, rights and resources 9.
The global birthing community may vary greatly and can include anything from traditional midwives to highly educated medical specialists. Venues may include dirt floor huts or clinically sterile rooms. Birthing women may be malnourished or affluently healthy and have various levels of understanding, but human dignity in birth can be maintained in any of these situations 10.
So why is reducing birth trauma for women important for the common good of the whole community? How mothers feel post birth influences the physiological maternal-infant bonding that occurs 5. This has an effect on breastfeeding, infant behaviour and psychosocial stability 5. Later social development for that child may also be affected 5. Maternally, birth trauma is related to the long-term mental health problems 10 and affects their capacity to flourish and be an active participant in the community.
When looking at the broader picture of women’s equity in the local community, we see the influence of women’s active participation. The Victorian government reports that economic productivity and business profitability would increase with more women in the workforce and in leadership. It states that establishing gender equity creates safer and healthier communities. It also recognises that the best way to prevent violence against women is to promote gender equity 11.
Globally, the recent reports on the status of the UN’s goal shows reductions in childhood marriage, down 5%, and female genital mutilation, slightly down to 200 million. There has been an increase of 2.6% in the number of women in parliament, 3% in management and positive progress in sexual and reproductive health decision making and education. But these changes are not enough. There is still a lot to be done to achieve gender equity and women’s empowerment in order to attain human rights for everyone 3.
I have discussed women’s gender equity issues in my local and the global community. Within my current and future professions, I would like to see some changes made. I would like to witness birth trauma rates at justifiable levels. I would like to see women treated with human dignity in childbirth. I would like to see the UN’s Sustainable Development Goal of achieving gender equity—empowering all women and girls—realised and our local and global population flourishing.
(1) United Nations. Goal 5: Achieve gender equality and empower all women and girls https://www.undp.org/content/undp/en/home/sustainable-development-goals/goal-5-gender-equality.html (accessed Jan 10, 2020).
(2) Manuel Velasquez; Claire Andre; Thomas Shanks; S. J. Meyer; Michael J Meyer. The Common Good.
(3) UNFPA. Frequently asked questions about gender equality https://www.unfpa.org/resources/frequently-asked-questions-about-gender-equality (accessed Jan 8, 2021).
(4) Dempsey, R. Birth Rights and the Hidden Threat of Obstetric Violence. Crikey.com.au. March 8, 2018.
(5) Anderson, C. A. The Trauma of Birth. Health Care Women Int. 2017, 38 (10), 999–1010. https://doi.org/10.1080/07399332.2017.1363208.
(6) Lokugamage, A. Royal College of Obstetricians and Gynecologists 2014 World Congress, 2014.
(7) Bohren, M. A.; Mehrtash, H.; Fawole, B.; Maung, T. M.; Balde, M. D.; Maya, E.; Thwin, S. S.; Aderoba, A. K.; Vogel, J. P.; Irinyenikan, T. A.; Adeyanju, A. O.; Mon, N. O.; Adu-Bonsaffoh, K.; Landoulsi, S.; Guure, C.; Adanu, R.; Diallo, B. A.; Gülmezoglu, A. M.; Soumah, A.-M.; Sall, A. O.; Tunçalp, Ö. How Women Are Treated during Facility-Based Childbirth in Four Countries: A Cross-Sectional Study with Labour Observations and Community-Based Surveys. The Lancet 2019, 394 (10210), 1750–1763. https://doi.org/10.1016/S0140-6736(19)31992-0.
(8) Maung, T. M.; Show, K. L.; Mon, N. O.; Tunçalp, Ö.; Aye, N. S.; Soe, Y. Y.; Bohren, M. A. A Qualitative Study on Acceptability of the Mistreatment of Women during Childbirth in Myanmar. Reprod. Health 2020, 17 (1), 56. https://doi.org/10.1186/s12978-020-0907-2.
(9) Betron, M. L.; McClair, T. L.; Currie, S.; Banerjee, J. Expanding the Agenda for Addressing Mistreatment in Maternity Care: A Mapping Review and Gender Analysis. Reprod. Health 2018, 15 (1), 143. https://doi.org/10.1186/s12978-018-0584-6.
(10) Curtin, M.; Savage, E.; Leahy‐Warren, P. Humanisation in Pregnancy and Childbirth: A Concept Analysis. J. Clin. Nurs. 2020, 29 (9–10), 1744–1757. https://doi.org/10.1111/jocn.15152.
(11) The benefits of gender equality https://www.vic.gov.au/benefits-gender-equality (accessed Jan 9, 2021).
As well as the oral presentation we presented a health promotion flyer and website about Anti-D.
9/7/2020 0 Comments
In recent years there have been fewer Australians drinking but an increased use in illicit drugs such as cannabis (+1.2%), cocaine (+1,7%) and ecstasy (+0.8%) 1. Misuse is defined as the use of these substances outside of medical prescription or law 2. When it is evident that a pregnant woman is misusing illicit drugs or alcohol, the enforcement of mandatory reporting for child abuse can seem appropriate. It is important that health care professionals (HCPs) are able to evaluate this in an ethical framework 3 to ensure their responses are based on benefit to the sick and the promotion of health and life. In this essay I will argue that enforcing mandatory reporting is not the correct course of action and in fact would create more harm than potential benefit. I will address the counter arguments and base my thesis on Beauchamp and Childress’s 3 principles of autonomy, justice, beneficence and non-maleficence. This will be done by examining the pregnant woman’s rights, where the duty of carers lies and what some of the potential outcomes may be for the mother, her foetus, her future child and the greater community.
It is extremely hard to get accurate statistics about alcohol and drug use in pregnancy due to screening and diagnosis issues 4. However there is research to show that 25% of Australian babies born to mothers who consumed alcohol during pregnancy were diagnosed with fatal alcohol spectrum disorder (FASD) 5. Moreover it is estimated 10-20% of pregnant women in the USA exposed their newborns to neonatal abstinence syndrome (NAS) 6,4.
It could be argued that with these statistics, all such pregnant women should be reported for child abuse because the vulnerable unborn child is at an increased risk of harm. It cannot articulate its right to life and should be protected. The argument is that ethical principles should be applied to the unborn foetus as they would to an independent human. However, this is a hard argument to put forward, as the foetus is only a future child because of the incubation of the mother’s body. To make this argument, according to Karpin 7 renders the woman’s body irrelevant and a “complex process of disappearing has to take place”. There is a long held belief that the foetus may be a human in-utero, but only gains personhood at birth 8.
In Wilkinson et al.’s 5 counter argument paper about protecting future children, they propose legal actions that could be taken against the mother post-natally for in-utero harm. This could lead to a maternal decision to terminate the pregnancy. In order to avoid harm to the foetus, they also suggest termination as a possible pre-natal intervention, and instating mandatory termination where the pregnant woman has drunk heavily. These statements appear somewhat counter-intuitive to their argument for protection and only highlight the importance of the woman in this situation.
Without removing the mother from the equation as Karpin 7 mentions and accepting that the foetus is connected and a part of her body 9, there is a need to ensure her autonomy is respected. Autonomy is defined as the ability to make choices about oneself that are free of any control, interference or limitations from others 10. Moreover is that these choices be morally respected and that all actions are performed with informed consent 11. Informed consent is the assumption that the person knows their choices and can refuse 12. As a HCP, autonomy may conflict with what is considered to be ‘doing the right thing’ or ‘doing no harm’ 13, however these concepts of beneficence and non-maleficence will be addressed later in the argument. Reporting this woman would be a violation of her right to autonomy as it would not be a choice she would be making freely.
A woman’s right to fair justice too, is a basic human need 14. This includes the justice to receive unbiased healthcare, to offer her the best opportunity of flourishing and living without offence in society 15. This Natural Law theory also supports the double effect principle where intentionally caring for and not reporting the pregnant woman may have a foreseen outcome of continuing harm to the foetus, but is still seen as morally permissible 16.
When considering what is permissible, HCPs are bound by their objective duty of care based on reason and the rules of their profession 17. Midwives are bound by their code to place the interests of the woman before all else, share the decision making and support her right to refuse 18. Along with other human rights of freedom 19, these form part of what can be explained as the theory of Deontology. This theory is based on intellectual moral obligations of right and wrong and the binding duty to uphold them 17. These duties help ground the argument against mandatory reporting and are also supported by legal regulations. The foetus has no legal rights as a child until they are born alive 20 and there are no rules in Australia implementing mandatory reporting for an expectant mother who misuses alcohol or illicit drugs. There is an exception only in Tasmania in conditions where there is a high likelihood of severe neglect and harm to the future infant 21.
In situations where an expectant mother is found to be misusing illicit drugs and alcohol, the HCP has the opportunity to ‘do good’ by providing appropriate treatment that will benefit the woman 16. This principle of doing good is known as beneficence 3 and can be used to build a therapeutic relationship based on trust 22. Patients respond more favourably to recommendations when they trust their professional and feel less vulnerable 23. Providing transparency, confidentiality and avoiding harm and abandonment are ways to reduce the feeling of vulnerability in the woman, gain her trust and increase her honesty 24. Barnard 24 also mentions that “[b]ehaviors alone do not give us all the information we need to make accurate judgments” and this increased connection can open opportunities to get to the origin of the misuse. Counselling, support and education are widely supported measures that may ultimately lead to better outcomes for the mother 5 and consequently, the foetus and future child.
This way of ethically looking at the overall, ultimate outcome of a situation where the ends justifies the means and where more good will be produced than harm, is called Consequentialism 17. This theory can be applied to the greater community where it can be assessed if reporting the woman would be better for society or not 25. Mandatory reporting would impact others in the mothers’ family, social group and the greater public 26. Depending on the type and level of usage, negative impacts like those of displacement of other family members, legal proceedings, job disruptions, emotional trauma and a greater societal resource expense of reporting management need to be considered.
Avoiding these negative impacts can be defined as ‘doing no harm’ which is the principle of non-maleficence 26. The harms of reporting the mother can be weighed against the principle of beneficence to produce a net benefit over harm 27. In this situation maleficent acts on the mother may include being judgemental, patriarchal, stigmatising and removing her autonomy. Should a person be deprived of what they most value, this deprivation is “often worse than the disease we are attempting to cure” 28.
While the arguments have been focused on respecting the pregnant woman and acknowledging the duty of care towards her, it is worth still recognising the impact of the situation on the unborn and future child. Even though the foetus has no legal status, it is still significant in a moral sense and worth considering 5,29. Whether an HCP has a legal duty or not, they may still want to think of themselves as ‘doing the right thing’ ethically for the foetus. This principle is known as Virtue Ethics and focuses on the act of enabling human flourishing, in this case the foetus 16,26. This can be done by finding the middle path and avoiding any extremes 17. This has been accomplished in the previous arguments where focussing on the wellbeing of the woman ultimately has the best chance of the un-born child having more favourable outcomes.
Clearly then, there is no reason mandatory reporting for child abuse should be a requirement for pregnant women who misuse alcohol or drugs. It has been shown that the abuse is not imposed on a child, but on an unborn foetus and therefore, by definition, the woman herself. Using Childress & Beauchamp’s 10 four principles as an acceptable basis for medical ethics evaluation 13, it was argued that a woman’s autonomy and right to fair justice should be respected and that the HCP has an obligation to respond within their duty of care and legal parameters. However, it was also identified in research that the HCP has a unique opportunity to therapeutically support the woman’s situation through gained trust, to increase her potential for healthier outcomes. By refraining from reporting, no intentional action of harm has been made and the outcomes for both mother, foetus and future child have been improved.
(1) Australian Institute of Health & Welfare. National Drug Strategy Household Survey 2019: In Brief. 2019, 104. https://doi.org/10.25816/e42p-a447.
(2) World Health Orgnization. Lexicon of Alcohol and Drug Terms Published by the World Health Organization. 2006 http://www.who.int/substance_abuse/terminology/who_lexicon/en/ (accessed Sep 7, 2020).
(3) Beauchamp, T.; Childress, J. Principles of Biomedical Ethics, 7th ed.; Oxford University Press: New York, 2013.
(4) Price, H. R.; Collier, A. C.; Wright, T. E. Screening Pregnant Women and Their Neonates for Illicit Drug Use: Consideration of the Integrated Technical, Medical, Ethical, Legal, and Social Issues. Front. Pharmacol. 2018, 9, 961. https://doi.org/10.3389/fphar.2018.00961.
(5) Wilkinson, D.; Skene, L.; De Crespigny, L.; Savulescu, J. Protecting Future Children from In-Utero Harm: Protecting Future Children from In-Utero Harm. Bioethics 2016, 30 (6), 425–432. https://doi.org/10.1111/bioe.12238.
(6) Wabuyele, S. L.; Colby, J. E.; McMillin, G. A. Detection of Drug-Exposed Newborns. Ther. Drug Monit. 2018, 40(2), 166–185. https://doi.org/10.1097/FTD.0000000000000485.
(7) Karpin, I. The Uncanny Embryos: Legal Limits to the Human and Reproduction Without Women. 2006, 28, 26.
(8) Jarvis Thomson, J. A Defense of Abortion. Philos. Public Aff. 1971, 1 (1), 47–66. https://doi.org/10.2307/2265091.
(9) Savell, K. The Legal Significance of Birth. Univ. New South Wales Law J. 2006, 29 (2), 200–206.
(10) Childress, J.; Beauchamp, T. Principles of Biomedical Ethics, 5th ed.; Oxford University Press, 2001.
(11) International Confederation of Midwives. International Code of Ethics for Midwives https://www.internationalmidwives.org/assets/files/general-files/2019/10/eng-international-code-of-ethics-for-midwives.pdf.
(12) Frye, A. Holistic Midwifery: A Comprehensive Textbook for Midwives in Homebirth Practice; Labrys Press: Portland, Oregon, USA, 1995.
(13) Gillon, R. Defending the Four Principles Approach as a Good Basis for Good Medical Practice and Therefore for Good Medical Ethics. J. Med. Ethics 2015, 41 (1), 111–116. https://doi.org/10.1136/medethics-2014-102282.
(14) Johnstone, M.-J. Nursing and Justice as a Basic Human Need: Nursing and Justice as a Basic Human Need. Nurs. Philos. 2011, 12 (1), 34–44. https://doi.org/10.1111/j.1466-769X.2010.00459.x.
(15) Ozolins, J. Ethical Principlism. In Foundations of healthcare ethics : theory to practice; Cambridge University Press: Port Melbourne, Vic., 2015.
(16) Kerridge, I.; Lowe, M.; Stewart, C. Principle-Based Ethics. In Ethics and law for the health professions; The Federation Press: Leichhardt, NSW, 2013.
(17) Ozolins, J.; Grainger, J. Foundations of Healthcare Ethics : Theory to Practice; Cambridge University Press: Port Melbourne, Vic., 2015.
(18) Nursing and Midwifery Board of Australia. Code of Conduct for Midwives. Nursing and Midwifery Board of Australia. 2018.
(19) United Nations. Universal Declaration of Human Rights https://www.un.org/en/universal-declaration-human-rights/index.html (accessed Aug 29, 2020).
(20) Forrester, K.; Griffiths, D. Manipulation of Life. In Essentials of law for health professionals; Elsevier Australia: Chatswood, NSW, 2010.
(21) Heyes, N. Mandatory Reporting of Child Abuse and Neglect CFCA Resource Sheet; Australian Institute of Family Studies, 2020; p 10.
(22) WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience; World Health Organization, Ed.; World Health Organization: Geneva, 2016.
(23) Paulsen, J. E. Ethics of Caring and Professional Roles. Nurs. Ethics 2011, 18 (2), 201–208. https://doi.org/10.1177/0969733010392302.
(24) Barnard, D. Vulnerability and Trustworthiness: Polestars of Professionalism in Healthcare. Camb. Q. Healthc. Ethics 2016, 25 (2), 288–300. https://doi.org/10.1017/S0963180115000596.
(25) Mandal, J.; Ponnambath, D.; Parija, S. Utilitarian and Deontological Ethics in Medicine. Trop. Parasitol. 2016, 6(1), 5. https://doi.org/10.4103/2229-5070.175024.
(26) Freegard, H. Ethics in a Nutshell. In Ethical practice for health professionals; Cengage Learning Australia, 2012.
(27) Gillon, R. Medical Ethics: Four Principles plus Attention to Scope. BMJ 1994, 309 (6948), 184. https://doi.org/10.1136/bmj.309.6948.184.
(28) Handerson, V. The Nature of Nursing : A Definition and Its Implications for Practice, Research, and Education : Reflections after 25 Years; National League for Nursing Pres: New York, N.Y, 1991.
(29) United Nations. Convention on the Rights of the Child https://www.ohchr.org/en/professionalinterest/pages/crc.aspx.
Care Model Comparison
I will firstly describe two of the models of care available to women at this health service: the maternity group practice (MGP) and general practitioner (GP) shared care. I will then compare these options using evidence-based material to support her making an informed choice 1,2.
MGP, also known as caseload midwifery, is a maternity model where all pregnancy, birth and postnatal care are provided by a primary midwife with the assistance of a backup or secondary midwife 1. GP shared care is a collaboration between a qualified community GP and the local hospital. The GP sees the woman for most of the antenatal care with selected appointments and the birth taking place at the nominated hospital with shift midwives 3.
Under MGP, midwives are trained to support and be attuned to the normal physiological processes of pregnancy, birth and breastfeeding and can detect deviations from this 4. This model enables care and support by a known midwife in a continuity of care approach. It has decreased rates of instrumental birth, episiotomy, regional analgesia use, and amniotomy, and higher rate of spontaneous vaginal birth 5,6. It also has higher incidences of water immersion, physiological third stage, second-degree tears 6, longer labours and less likelihood of adverse fetal and neonatal outcomes 5. It is therefore not surprising that this mode of care is in high demand and consequently can be difficult to access 3.
A more accessible choice is the GP shared care model offering some continuity of care, especially in the broader lifespan context. With this model the woman can choose their general practitioner who can offer convenience in location and access to appointments, as well as offer more culturally and language appropriate choices 7. However, GPs need to complete extra specialist training in maternity care to offer this option 8 and are often not equipped to offer satisfactory breastfeeding and nutritional information 9,10.
Both models cover the standard pre-, post- and intra-partum care through public funding 1. They offer intrapartum care in a local hospital predominantly supported by midwives and they both adhere to timely consultation and referral guidelines 11. The GP program reports positive satisfaction levels 9, but the outcomes for babies and maternal satisfaction rate is higher in MGP models than in standard care, including GP shared care 5,12.
Satisfaction also comes when a woman feels she has sufficient information to choose a model of maternity care 13. These two options would give her a choice of continuity of care led by midwives with higher rates of normal physiological birth or familiarity of care with her own general practitioner. Offering a woman informed choice typically enables collaboration and the right to autonomy and self-determination.
Iron Deficiency Anamia Case Study
I will describe how therapeutic information will be provided within a midwifery group practice model of care to a woman found to have iron deficiency anaemia, and how care will be planned in partnership with her relating to this.
As early antenatal care providers, group practice midwives are in an important position to identify anaemia in pregnant women, determine the underlying causes and guide best choice management of the condition 14. Iron deficiency anaemia (IDA) is characterised by a haemoglobin level below 110 g/L in the first and third trimesters or below 105 g/L in the second trimester 15,16, along with a serum ferritin level less than 30 μg/L 17. In this woman’s case, her ferritin levels were under 15 μg/L which indicated iron depletion 18. After review, the midwife can discuss the results with the woman at her next antenatal visit 19. This can include explaining that iron is required to transport oxygen around our body and that these levels can drop in pregnancy due to increased blood volume and demand, but that her results were outside of what would be expected.
In order to provide quality continuity of care, this woman’s whole clinical story needs to be considered to make suitable recommendations 20. Firstly, this can done by asking how she is feeling and validating any linked common symptoms such as general fatigue, weakness and depression 21. Assessing her health literacy around the diagnosis and ensuring she comprehends what these results mean is important 22. The midwife can invite the woman to express what she understands and provide more or clearer information if necessary. When this understanding is established, the midwife can also explain how low iron levels are linked to premature and small babies, increased infection, birth complications and ante- and post-natal depression 15.
The midwife can revisit the woman’s current nutrition and supplement intake and can offer a recommendation 24 to consume more lean red meat, eggs and chicken. Other great iron-rich foods to recommend, especially if the woman does not eat animal products, are fermented wholegrain foods, fortified cereals, dried fruit, roasted nuts, seeds, green leafy vegetables, blackstrap molasses, Marmite, Vegemite and soaked legumes 25. To assist in iron absorption, food rich in vitamin-C can also be added to this list, such as citrus fruits, kiwifruit and broccoli 25. The midwife can also recommend limiting the intake of calcium, zinc, black tea, and red wine in conjunction with iron intake; these substances can inhibit iron uptake into the body 25,15.
It is unlikely that diet alone can offer improvements given the woman’s circulating and stored iron levels and reasonably common for midwives practicing continuity of care to prescribe supplementation 26. It is recommended that she commence oral iron supplementation of 100 mg as a first line treatment to be taken separately instead of in a multivitamin. This recommendation can be offered while encouraging the woman to ask questions to make a fully informed decision about taking them.
Some of this conversation can include sharing the side effects and hazards of the supplements and how to minimise their effect. Side effects include constipation, diarrhoea, nausea and vomiting 27 with hazards of a raised haemoglobin risking placental insufficiency and secondary haemochromatosis 28. Recommendations to increase tolerance would include taking them at bedtime, with food that does not decrease absorption and lowering the dose or frequency 15,29. It is also worth considering and discussing what other barriers the woman may have in obtaining and taking the supplements and consuming iron-rich foods, such as financial, logistical or cultural difficulties.
The midwife can document the information and offer a plan to the woman in light of this diagnosis and discussion. It is anticipated that her haemoglobin levels should increase by about 10-20 g/L over the next three to four weeks while taking the supplements 30. This plan would include retesting in about two weeks 14 and again at 36 weeks gestation 19. If the follow-up blood tests do not show expected improvements, intravenous iron supplementation should be offered 14. If any tests show her haemoglobin level has dropped below 90 g/L, the midwife should seek consultation with a medial practitioner 31. All this clinical information can be conveyed to the woman at the appropriate times as their relationship is built.
Through close investigation of the journey of this woman’s IDA diagnosis, it is clear to see the benefits of continuity of care in ensuring safe, evidence-based, woman-centred midwifery care. This has been achieved with holistic, therapeutic communication of the relevant information with key decisions made in close partnership with the woman and the MGP midwife.
(1) COAG Health Council. Woman-Centred Care: Strategic Directions for Australian Maternity Services. Department of Health August 2019.
(2) International Confederation of Midwives. International Code of Ethics for Midwives.
(3) Homer, C. S. Models of Maternity Care: Evidence for Midwifery Continuity of Care. Med. J. Aust. 2016, 205 (8), 370–374. https://doi.org/10.5694/mja16.00844.
(4) Frye, A. Holistic Midwifery: A Comprehensive Textbook for Midwives in Homebirth Practice; Labrys Press: Portland, Or. (7528 NE Oregon St., Portland 97213), 1995.
(5) Sandall, J.; Soltani, H.; Gates, S.; Shennan, A.; Devane, D. Midwife-Led Continuity Models versus Other Models of Care for Childbearing Women. Cochrane Database Syst. Rev. 2016. https://doi.org/10.1002/14651858.CD004667.pub5.
(6) Gidaszewski, B.; Khajehei, M.; Gibbs, E.; Chua, S. C. Comparison of the Effect of Caseload Midwifery Program and Standard Midwifery-Led Care on Primiparous Birth Outcomes: A Retrospective Cohort Matching Study. Midwifery2019, 69, 10–16. https://doi.org/10.1016/j.midw.2018.10.010.
(7) Better Health Channel. Pregnancy and birth care options https://www.betterhealth.vic.gov.au/health/ServicesAndSupport/pregnancy-and-birth-care-options (accessed Aug 15, 2020).
(8) Conjoint Committee; CCDOG. Shared Maternity Care Obstetric Patients; Conjoint Committee for the Diploma of Obstetrics and Gynaecology, 2016.
(9) Lucas, C.; Charlton, K.; Brown, L.; Brock, E.; Cummins, L. Review of Patient Satisfaction with Services Provided by General Practitioners in an Antenatal Shared Care Program. 2015, 5.
(10) Walker, R.; Choi, T. S. T.; Alexander, K.; Mazza, D.; Truby, H. ‘Weighty Issues’ in GP-Led Antenatal Care: A Qualitative Study. BMC Fam. Pract. 2019, 20 (1), 148. https://doi.org/10.1186/s12875-019-1026-4.
(11) Women’s Health Committee. Maternal Suitability for Models of Care, and Indications for Referral within and between Models of Care. The Royal Austraian and New Zealand College of Obstetricians and Gynaecologists March 2018.
(12) Forster, D. A.; McLachlan, H. L.; Davey, M.-A.; Biro, M. A.; Farrell, T.; Gold, L.; Flood, M.; Shafiei, T.; Waldenström, U. Continuity of Care by a Primary Midwife (Caseload Midwifery) Increases Women’s Satisfaction with Antenatal, Intrapartum and Postpartum Care: Results from the COSMOS Randomised Controlled Trial. BMC Pregnancy Childbirth 2016, 16 (1), 28. https://doi.org/10.1186/s12884-016-0798-y.
(13) Stevens, G.; Miller, Y. D.; Watson, B.; Thompson, R. Choosing a Model of Maternity Care: Decision Support Needs of Australian Women. Birth 2016, 43 (2), 167–175. https://doi.org/10.1111/birt.12212.
(14) Frayne, J.; Pinchon, D. Anemia in Pregnancy. Hematol. Oncol. Clin. North Am. 2019, 25 (2), 241–259. https://doi.org/10.1016/j.hoc.2011.02.001.
(15) Milman, N.; Paszkowski, T.; Cetin, I.; Castelo-Branco, C. Supplementation during Pregnancy: Beliefs and Science. Gynecol. Endocrinol. 2016, 32 (7), 509–516. https://doi.org/10.3109/09513590.2016.1149161.
(16) Daru, J.; Cooper, N. A. M.; Khan, K. S. Systematic Review of Randomized Trials of the Effect of Iron Supplementation on Iron Stores and Oxygen Carrying Capacity in Pregnancy. Acta Obstet. Gynecol. Scand. 2016, 95 (3), 270–279. https://doi.org/10.1111/aogs.12812.
(17) RCPA. Iron Studies Standardised Reporting Protocol; The Royal College of Pathologists of Australia, 2013; p 16.
(18) Pavord, S.; Myers, B.; Robinson, S.; Allard, S.; Strong, J.; Oppenheimer, C.; on behalf of the British Committee for Standards in Haematology. UK Guidelines on the Management of Iron Deficiency in Pregnancy. Br. J. Haematol.2012, 156 (5), 588–600. https://doi.org/10.1111/j.1365-2141.2011.09012.x.
(19) Department of Health. Clinical Practice Guidelines: Pregnancy Care; Australian Government Department of Health: Canberra, 2018.
(20) Grigg, C. Working with Women in Pregnancy. In Midwifery : preparation for practice; Elsevier Australia: Chatswood, AUSTRALIA, 2019; p 44.
(21) Milman, N. Oral Iron Prophylaxis in Pregnancy: Not Too Little and Not Too Much! J. Pregnancy 2012, 2012, 1–8. https://doi.org/10.1155/2012/514345.
(22) Australian Commission on Safety and Quality in Health Care. HEALTH LITERACY: Taking Action to Improve Safety and Quality; ACSQHC: Sydney, 2014.
(23) Chatterjee, N.; Fernandes, G. ‘This Is Normal during Pregnancy’: A Qualitative Study of Anaemia-Related Perceptions and Practices among Pregnant Women in Mumbai, India. Midwifery 2014, 30 (3), e56–e63. https://doi.org/10.1016/j.midw.2013.10.012.
(24) Chatterjee, R.; Shand, A.; Nassar, N.; Walls, M.; Khambalia, A. Z. Iron Supplement Use in Pregnancy – Are the Right Women Taking the Right Amount? Clin. Nutr. 2016, 35 (3), 741–747. https://doi.org/10.1016/j.clnu.2015.05.014.
(25) Wratten, J.; Gibbons, M. Nutrition and Physical Activity Foundations for Pregnancy, Childbirth and Lactation. In Midwifery Preparation for Practice; Pairman, S., Tracy, S. K., Dahlen, H. G., Dixon, L., Eds.; 2019; pp 404–423.
(26) Hunter, M.; Davis, D. Pharmacology and Prescribing. In Midwifery Preparation for Practice; Pairman, S., Tracy, S. K., Dahlen, H. G., Dixon, L., Eds.; 2019; pp 707–733.
(27) Peña-Rosas, J. P.; De-Regil, L. M.; Dowswell, T.; Viteri, F. E. Daily Oral Iron Supplementation during Pregnancy. In Cochrane Database of Systematic Reviews; The Cochrane Collaboration, Ed.; John Wiley & Sons, Ltd: Chichester, UK, 2012; p CD004736.pub4. https://doi.org/10.1002/14651858.CD004736.pub4.
(28) Ribot, B.; Aranda, N.; Giralt, M.; Romeu, M.; Balaguer, A.; Arija, V. Effect of Different Doses of Iron Supplementation during Pregnancy on Maternal and Infant Health. Ann. Hematol. 2013, 92 (2), 221–229. https://doi.org/10.1007/s00277-012-1578-z.
(29) Peña-Rosas, J. P.; De-Regil, L. M.; Gomez Malave, H.; Flores-Urrutia, M. C.; Dowswell, T. Intermittent Oral Iron Supplementation during Pregnancy. Cochrane Database Syst. Rev. 2015. https://doi.org/10.1002/14651858.CD009997.pub2.
(30) Percy, L.; Mansour, D.; Fraser, I. Iron Deficiency and Iron Deficiency Anaemia in Women. Best Pract. Res. Clin. Obstet. Gynaecol. 2017, 40, 55–67. https://doi.org/10.1016/j.bpobgyn.2016.09.007.
(31) Australian College of Midwives Ltd. ACM C&R Guidelines; Australian College of Midwives Ltd.: Apple App store, 2016.
Midwives are primary carers in our health system providing primary maternity care which is grounded in evidence-based maternal health care and is centred around the woman . This essay will discuss how primary care and primary health care differ and how primary health care provided by midwives contributes to healthy outcomes for women and their babies. Firstly, it will define and address the differences between primary care and primary health care. Next, it will explain how midwives work as primary health care providers and finally it will present how midwifery-led primary health care contributes to healthy maternal and neonate outcomes.
It is incorrect to use the terms ‘primary care’ and ‘primary health care’ as if they are interchangeable and this is why clear definitions are important . Primary care is a therapeutic service delivered in the community that is often a person’s entry point into a medical system focussed on illness diagnosis, treatment and/or referral . The primary carer is the initial practitioner and has the greatest responsibility and can include general practitioners, pharmacies, allied and community health providers and midwives .
The term ‘primary health care’ is predominantly used to refer to a public health philosophy that provides essential, consumer acceptable healthcare services to the greater population that are equitably accessible to individuals, families and the community . Primary health care is committed to addressing dominant health problems at a society level, promoting individual and community self-reliance and participation, ensuring suitable health education is delivered and is connected to all other sectors in relation to community development . Examples would be vaccinations or hand-sanitation in a viral pandemic.
Primary health care focusses on the broader community’s health as a whole, ensuring social and economic development that is affordable and logistically attainable to all in the community in need and involves interdisciplinary collaboration. Primary care, on the other hand, focusses on sustaining individual health and maintaining relationships over time.
Midwives, although not generally diagnosing and treating illness, are seen as primary carers as they are often the entry point into the maternity health system. Their scope of practice closely aligns with primary health care in providing antenatal, labour and birth and postnatal care that is woman-centred, geographically accessible, holistic and supports the woman’s full participation in taking ownership of her health and wellbeing . Midwives work as part of a team, often referring to secondary and tertiary health services.
Many of these values and principles are reflected in the International Confederation of Midwives’ Codes of Ethics  and the Nursing and Midwifery Board of Australia’s Code of Conduct for Midwives . These documents also emphasise the point that maternal health is not just about the access to pregnancy, birth and newborn care, but is a greater public health issue. Important in this greater issue is the integration of referral pathways. This is usually for a particular purpose and for care that is outside the midwife’s expertise or scope of practice .
Eddy  mentions that midwives are also mindful of power and service access inequality and are often involved in political activism to ensure that women receive the care that they need and are entitled to. This involves the human right to engage with services that incorporate ‘body, mind, spirit, land, environment, culture, custom and the social determinants of health’ .
The social determinants of health that may affect midwifery healthcare include and are not limited to, genetics, healthy child development, social support networks, education, social and physical environments, health practices and services and culture. . Health is a multi-faceted state of being that includes biological, social and ecological factors within the societal environment .
Midwives offer care with the belief that most women are healthy, and childbearing is a normal physiological process. Midwives are looked at as ‘guardians of the normal’  and are not illness focussed. Healthy outcomes for women and children are expected and these results are being reflected within primary maternity care settings.
Sandall’s  Cochrane review suggests that midwife-led continuity of care increases a women’s likelihood of, being more satisfied with her birth, having fewer interventions and analgesia and being with a midwife she knows for the process. Babies are also less likely to be born early and are at a lower risk of mortality . A more recent Australian study evaluating a caseload midwifery program revealed similar favourable findings . This further supports how primary health care provided by midwives contributes to healthy outcomes for women and their babies, maximising the gains that can be achieved during maternity care . Healthy outcomes also rely on the aforementioned collaborative and supportive infrastructure being in place to assist midwives to provide comprehensive primary health care to cover any of these facets outside of their scope .
In summary, the difference between primary care and primary health care is one of scope. Primary care is concerned with meeting individual clients’ needs, while primary health care considers outcomes for the entire community.Working as primary carers, midwives also perform a broader function in the primary health care system by supporting and educating the woman and families in their care, and advocating for holistic equality to access basic health services leading to better health outcomes for society.
1. Nursing and Midwifery Board of Australia, Midwife standards for practice. 2018.
2. Muldoon, L.K., W.E. Hogg, and M. Levitt, Primary care (PC) and primary health care (PHC). What is the difference? Canadian Journal Of Public Health = Revue Canadienne De Sante Publique, 2006. 97(5): p. 409-411.
3. Eddy, A., Midwifery as primary healthcare, in Midwifery Preparation for Practice, S. Pairman, et al., Editors. 2019. p. 79-88.
4. The Australian Government Department of Health. Primary care. 2020 [cited 2020 April 05, 2020]; Available from: https://www1.health.gov.au/internet/main/publishing.nsf/Content/primarycare.
5. World Health Organisation. Declaration of Alma-Ata. 1978 [cited 2020 6/8/2020]; Declaration of Alma-Ata]. Available from: https://www.who.int/publications/almaata_declaration_en.pdf.
6. International Confederation of Midwives. International Code of Ethics for Midwives. 2008 2014.
7. Nursing and Midwifery Board of Australia, Code of conduct for midwives. 2018, Nursing and Midwifery Board of Australia.: https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx.
8. McMurray, A. and J. Clendon, Community Health and Wellness - E-Book : Primary Health Care in Practice. 2014, Chatswood, AUSTRALIA: Elsevier Health Sciences.
9. Leap, N., Promoting physiological birth, in Midwifery Preparation for Practice, S. Pairman, et al., Editors. 2019. p. 347-361.
10. Sandall, J., Midwife-led continuity models versus other models of care for childbearing women (Review) Midwife-led continuity models versus other models of care for childbearing women (Review). Cochrane database of systematic reviews (Online), 2013: p. Art. No.: CD004667.
11. Gidaszewski, B., et al., Comparison of the effect of caseload midwifery program and standard midwifery-led care on primiparous birth outcomes: A retrospective cohort matching study. Midwifery, 2019. 69: p. 10-16.
‘Birth for Humankind’ fosters strong community engagement by working with women and babies who present with complex needs. By increasing their confidence and knowledge and supporting them to overcome language and cultural barriers in the maternal health system, Birth for Humankind improves the health and wellbeing outcomes for these groups .
The word ‘community’ within the definition of ‘community engagement’ is defined as a group brought together by either geographical location, special interest, shared circumstances or a common vision [2-4]. Birth for Humankind was established to work with the Melbourne community of women at risk during their pregnancy, birth and post-partum period.
This community includes women who are
When defining ‘engagement’ many words will present including collaboration, participation, connection and communication, but all involve some form of action or process to build relationship with the implication of benefitting the community [2-5]. Birth for Humankind does this by matching pregnant women with specifically trained doulas, providing education and informational support, ensuring language barriers are overcome, and offering continuity of emotional and physical care .
To further engage with this community, Birth for Humankind also provides education and information to the maternal health and allied service providers who support these women. This helps raise awareness of the barriers to respectful and appropriate maternity care faced by these women, and the impact this has on their health and wellbeing outcomes .
Birth for Humankind is a powerful example of community engagement, engaging with the community of birthing women in Melbourne who are experiencing additional challenges. This community engagement enables respectful, appropriate maternity care, for women to have the best birth possible and to improve the maternal and newborn health outcomes.
1. Birth for Humankind Annual Report FY18-19. 2019: Birth for Humankind.
2. Community engagement - A key strategy for improving outcomes for Australian families. 2016 [cited 2020 07/03/2020]; CFCA Paper No. 39 – April 2016:[Available from: https://aifs.gov.au/cfca/publications/community-engagement/what-community-engagement.
3. van Delden, J.J.M. and R. van der Graaf, Revised CIOMS International Ethical Guidelines for Health-Related Research Involving Humans. JAMA, 2017. 317(2): p. 25-27.
4. Bowen, F., A. Newenham-Kahindi, and I. Herremans, When Suits Meet Roots: The Antecedents and Consequences of Community Engagement Strategy. Journal of Business Ethics, 2010. 95(2): p. 297-318.
5. Emergency risk communication training - Module B5: Community Engagement. [cited 2020 09/03/2020]; Emergency risk communication training - Mudule B5: Community Engagement]. Available from: https://www.who.int/risk-communication/training/module-b/en/index4.html.
6. O’Rourke, K.M., et al., An Australian doula program for socially disadvantaged women: Developing realist evaluation theories. Elsevier, 2019.