Being more than physically safe.

The free-text survey responses demonstrated that women prioritised safety for themselves and their infants across their maternity care episode; however, emphasised the need for a holistic approach to safety, and the need to feel more than physically safe. In other words, women valued care that made them feel emotionally and psychologically safe just as much (and sometimes more than) care that provided physical safety. Women indicated that physical safety was often prioritised at the expense of other non-physical safety measures, contributing to an overall sense of feeling unsafe. Further, the provision of maternity care that was not emotionally or psychologically safe was often reported as leading to ongoing trauma postnatally, sometimes resulting in the need for women to seek mental health support. While it was acknowledged that Australia is generally considered a safe place to give birth, this was only with respect to physical safety, as stated by these participants:

Physical safety when giving birth in Australia is almost a given; our outcomes are similar no matter the place of birth. When talking about emotional, psychological, and feeling a sense of safety, that is very hard to find inside a hospital. (ID 928)

I think there needs to be a real effort to recognise that quality maternity care does not mean only providing safe physical care for women and their babies. Pregnancy, birth, and postpartum are often emotionally difficult and overwhelming, even in the best of circumstances. Expecting women to soldier through so much of these challenges alone is unacceptable and retrograde in 2023. Australia has one of the best healthcare systems in the world. Time to raise the bar on maternity services so that they also fit this description. (ID 217)

Further, the concept of safety was viewed as an individual measure that should be defined by the woman herself:

To me, safety refers not just to clinical knowledge and competency but also to the care that is provided with respect and with the goal of empowering women. Safety is defined by the woman receiving the care, and informed consent (without coercion or judgement) is an absolute necessity… to allow women to define what is safe for them and the level of risk they are comfortable with. (ID 1671)

Safety through individualised care.

The second sub-theme speaks to the importance of individualised maternity care and information provision to enhance women’s sense of safety, and how safety becomes compromised if this is lacking. Women who received care from multiple providers were more vulnerable to feeling that their safety was jeopardised, especially if conflicting information was provided by different health professionals, as described below:

I often felt judged throughout antenatal appointments and did not ask questions or engage in my care because I felt brushed off… like the midwife had no time for me. I did not necessarily believe the midwife’s information because most people gave differing information, and this made me feel extremely unsafe and uncomfortable, and instead of being cared for during my pregnancy made me feel like a box for the staff to tick. (ID 717).

I never saw the same midwife or doctor more than once. Each antenatal visit was someone new and every medical professional had a different opinion and spoke about different risks or things to worry about that when they were compounded made me very anxious. I didn’t have just one person to call on or trust. (ID 250).

Continuity of care with a known maternity care provider mitigated the risk of feeling unsafe, as the following women illustrate:

I felt incredibly safe with my obgyn [obstetrician-gynaecologist] and was able to have many discussions with her around the safety of my pregnancy and birth. I felt like my wishes were taken into account, and then also considered with safety in mind. (ID 889)

Having a known midwife to myself and my family helped to make myself and partner feel safe, it was someone we trusted to inform, educate, and assist in making the right decisions whilst allowing me to listen and follow my own intuition. Was amazing care. (ID 790)

Safety through staffing.

In the third sub-theme, participants described workforce shortages that were prevalent across the Australian maternity care system, particularly during the inpatient stay for intrapartum and immediate postnatal care. Staffing shortages in health care facilities were noticed by women in both public and private facilities, and this compromised their sense of safety:

Not having enough staff made it impossible to feel safe. (ID 339)

After the baby was born there was an extreme lack of assistance from midwives in the hospital. Midwives were only seen once a shift, and when asking for assistance nil was provided. I felt unsafe with the advice or lack of advice/assistance. (ID 505)

I was pushed into having an induction as there were concerns I had IUGR [intrauterine growth restriction]. I gave birth to a perfectly healthy baby. What felt unsafe was that I was told the induction was urgent and had to be done that day. I asked what was the latest we could leave it to see if I would go into spontaneous labour and was told we cannot leave it later. I was then told (due to staffing) they couldn’t book me in for an induction for 4 days. (ID 166)

Paramountcy of respectful relationships.

Respectful relationships with maternity care providers were highly valued by survey participants, and where this occurred, women felt empowered to make autonomous and informed decisions for themselves and their babies. Women described the need to have their decisions respected by their maternity care providers and the importance of being guided through the decision-making process in a way that valued the woman’s opinions and wishes. When this did not occur, women lacked trust in their care providers, and the therapeutic relationship became strained:

I am an intelligent, educated woman who just happened to be pregnant and giving birth. There seemed to be an attitude amongst caregivers that this diminished my ability to understand the risks of a certain situation or to make a rational decision. It feels very disrespectful of my status as a rational and capable adult, and anytime I spoke up, I was treated like a naughty child in a classroom. (ID 733)

With only one exception, I was spoken AT by doctors who didn’t take the time to find out my… background… or my appetite for risk. I could quote relevant statistics re my ‘high-risk’ pregnancy (gestational diabetes) better than they could, so I had the capacity to make my own decisions. Apart from one obstetrician, they didn’t seem to get that not all pregnant people want a ‘healthy baby above everything else.’ I was willing to tolerate a miniscule increase in risk to my child (late term stillbirth) to have a dramatically better chance of having my desired birth (vaginal birth with no intervention). I was borderline yelled at by an obviously contemptuous registrar for refusing an induction. (ID 2)

Feeling listened to and heard.

Throughout the survey, the importance of being listened to and heard by their maternity care provider was identified as a means of generating respect within the therapeutic relationship. It also served to ensure the woman felt in control of her maternity care, increased satisfaction with the care provided, and even served as a deterrent to negative emotions:

During pregnancy and birth, I was listened to at all stages, they answered all of my questions and asked for consent. It allowed me to make decisions and walk away from what could have been a traumatic birth, feeling comfortable and empowered. (ID 135)

I felt that my midwives and doctors always respected my decisions about my body even when I made requests that went against standard practice. This helped me to feel confident, calm, and psychologically safe. (ID 1286)

Conversely, not feeling listened to or heard by maternity care providers had a negative effect on the perception of care received, as stated below:

Providers need to LISTEN to women and not treat them like they don’t know what they’re experiencing and just placate them but go with their own agenda anyway. (ID 323)

I didn’t feel reassured by the midwives when I expressed concern or a preference for my birth. I didn’t feel heard, and being a first-time mum, I felt lost, and didn’t know what guidance I needed, what to expect in a public hospital birth, what… process to follow. (ID 996)

In addition, perceptions of being unheard could remain with women long after the postnatal period was complete and contributed to symptoms of birth trauma, as described by this woman:

Feeling unsafe and unheard during my pregnancy, birth, and postnatal period has lingered with me and I often find myself thinking about it in the middle of the night and replaying conversations and situations with my OB [obstetrician] and midwives and feeling angry and upset. (ID 930)

Interdisciplinary respect.

The interplay of relationships between different maternity care providers was observed by women participating in the survey, who noticed particularly where their relationship between providers was strained due to differing opinions of how care should be provided. This compromised women’s perceptions of respectful care, and they felt caught in the middle of the negative interdisciplinary interactions:

My obgyn [obstetrician-gynaecologist] and a midwife got in a fight in front of me. He was upset that she had not removed my catheter or helped me shower the day after my c-section [caesarean birth]. When he requested materials to remove my catheter, she got them and then left the room without assisting the doctor. They both complained about the other person separately in front of me. It was very awkward. (ID 363)

Further, the differing philosophy of care provision between medical practitioners and midwives was noticed by women and was described as confusing and unhelpful:

While my MGP midwife was excellent, there can sometimes be a bit of shade thrown between midwives and obstetricians (in both directions). The us versus them vibe is extremely unhelpful and makes all the material from both sides read like propaganda. (ID 1724)

There is still ongoing disagreement between doctor and midwife approaches to maternity care, I very much dislike passing on a comment from one member and having it disparaged by the other member. (ID 429)

Choice awareness, availability, and support.

Universally, women described a lack of awareness about the different maternity models of care locally available to them. They further outlined the requirement to choose a model of care in early pregnancy with little information provided about how the models worked and how this decision would later impact care provision across the maternity care episode. A lack of awareness meant that women often missed out on their model of choice, particularly public MGP models, as by the time they became aware of them, the models were already fully booked. Women also described the gatekeeping function of the general practitioner (GP) in guiding their decision regarding the model of care choice, which was often simplified into a decision between the public and private health systems. The following are examples of this situation:

I was most of the way through my pregnancy before even understanding the differences in models of care. Women are expected to lock in decisions very early in pregnancy without understanding the implications of those decisions on their care. (ID 1251)

The survey lists 11 forms of maternity care, but I didn’t get this list and wasn’t asked which one I would prefer… I was asked if I was going public or private and if I would choose shared care with my GP. That’s it. (ID 135)

It would be nice if medical professionals outlined ALL the available choices, not just those they personally agree with. My GP neglected to mention that home birth or private midwifery care were options, so it wasn’t until halfway through my pregnancy I had done all my research and changed to this option. I felt like I had to present all my reasoning to the GP for her to write a referral letter though, and she told me she hopes I don’t come back to her with birth trauma when I don’t get the magical water birth I want. Zero evidenced based advice there. (ID 344)

Women also discussed the need to have their care choices supported by their maternity care providers as it enabled them to feel empowered, respected, and in control of their decision making and care. Conversely, a lack of support for a woman’s decision had the opposite effect. The following two statements provide examples of how positive and negative support impacted choice:

I was pleasantly surprised that despite my birth not going at all to plan (unexpected home birth to a frank breech baby, no medical assistance present during) - paramedics, ED [emergency department] staff, and maternity staff all took the time to read my birth preferences and respected my choices. That gave me back a small amount of control in a very uncontrollable situation and it was much appreciated. (ID 808)

The first obstetrician who cared for me through my pregnancy was initially supportive of my wishes for a VBAC [vaginal birth after caesarean] as there were no medical reasons why I needed a repeat caesarean. Late in the pregnancy, he started to voice his opinions strongly about his preference for caesarean and imposed a lot of ‘conditions’ on my being ‘allowed’ to give birth vaginally. He became condescending and dismissive towards me when I asked for evidence-based information to support his preferences. I felt unsupported and abandoned. (ID 134)

Informed decision making.

Survey respondents stressed the importance of being given appropriate information to inform maternity care decision-making processes; however, many felt that this was often not provided by clinicians. This resulted in women consenting to procedures for themselves or their baby, which they later considered as provided without being truly informed. They also described being forced to ‘choose’ what their maternity care provider wanted for them rather than making the decision freely for themselves, and how this impacted their emotional well-being and sense of autonomy:

I never felt like I was provided with enough information... I feel like they purposely keep you a little bit in the dark so you can’t stand up for yourself and advocate for yourself, so if it comes down to it, they get to make that decision for what suits them best, rather than giving you all you need to decide for yourself. (ID 1676).

I felt like I was nominally given choice (e.g., sign here… for your emergency c section), but these were not real choices, as I wasn’t the best-informed person to know whether these procedures were truly necessary. I felt extremely disempowered and in many ways, the fact that these things were my ‘choice’ (but not really), made the whole thing emotionally much worse. (ID 1703).

I was not educated at all about relevant medical options when pregnant, nor ever asked or discussed different options for a birth plan. Procedures were done and medications administered to me… that I did not consent to or have explained to me beforehand. I felt powerless because of it. (ID 930).

Contrarily, women described the positive impact of informed decision-making, even when care deviated from expected outcomes:

I felt very informed about all my choices. Things didn’t go as I had hoped, but I feel absolutely fine about it because I was informed, felt in control, and not pressured. (ID 1624)

Coerced care.

Experiences of coercion in maternity care were commonly reported in the survey. Women described how feeling coerced by their maternity care providers negatively impacted their autonomy and preferences and led to tension:

I did NOT feel safe when in the presence of obstetricians, who pulled the ‘dead baby card’ without any evidence on two occasions. They clearly were… so convinced my baby was in danger that they made me sign an acknowledgement that I was refusing medical treatment. It was clear to me that they were just trying to coerce me into accepting an intervention (induction of labour) that, a) was risky, and b) was unnecessary. (ID 1093).

A jaded midwife ignored my requests for assistance, help with positioning, and general support during labour. I was left in unnecessary pain, and she ignored my birth plan wishes and coerced me into procedures I clearly didn’t want, all to make her shift at work easier… I felt dismissed, powerless, and still suffer physically 18 months on with still no answers as to what is causing my ongoing pain. (ID 268)

Postcode lotteries and payment for access.

Issues of access were commonly referred to in the survey responses, where women frequently described difficulty in accessing the care they wanted and needed, with a ‘postcode lottery’ seen as a possible explanation. Paying for care was seen as a solution to mitigate access problems, although, as one respondent suggested, ‘what you can afford determines your level of care and options available to you’ (ID 1246). Accessing care by paying for it was also acknowledged as a privilege and one that many could not afford. The following quotes illustrate these points:

Currently, it feels like a postcode lottery to access appropriate care. I got lucky and live in a reasonably well-serviced area. Friends and family that live only 15 minutes away had different experiences of care due to the postcode lottery. (ID 267)

I am very privileged to be located in (capital city), to be able to afford private health insurance and out-of-pocket costs for private medical and allied health services such as obstetrician/lactation consultant/postnatal physiotherapist, to speak English, and to have high health literacy, and access to informal medical advice via medical friends and medical social media groups. If any of these factors were flipped the other way, they would be barriers to accessing care. (ID 1716)

Private midwifery care is a good standard, and it costs a lot of money, however, it should be the minimum standard. My care was exceptional and helped me heal from a lot of previous traumas. Many women in Australia cannot afford this kind of care and therefore have no access to it. The Medicare and private health rebates are so low or non-existent it makes this type of care only accessible to the wealthy. (ID 1553)

Elusiveness of the gold standard.

Access to continuity of care with a care provider of choice, including midwifery continuity of care, is one of the principles in the Strategy. Although this was universally referred to as the ‘gold standard’ of maternity care and highly desired by women in the survey, women also described their difficulty in accessing midwifery continuity models. Private midwifery care was considered more accessible but was also seen as expensive and for some, cost prohibitive. Public MGPs were considered almost impossible to access due to the high demand exceeding availability. Women also described their disappointment at being ineligible to access MGP if deemed to be ‘at risk’, as some MGP models exclusively cater to low-risk women. The following quotes illustrate the situation:

Caseload midwife care is the gold standard. It’s an embarrassment to our healthcare system that all women can’t access this. It shows how undervalued women’s health is. (ID 88)

Accessing continuity of care in my area through the public hospital is almost impossible - not enough midwives in the program and too many women wanting access. We chose private midwifery for a number of reasons, but this was a very expensive option and definitely was a big investment, one that many simply cannot afford. (ID 1739)

Many women, like myself, who desire & apply for midwifery continuity, are unable to access it. I did not get in last pregnancy. Now pregnant again, it is not even an option for me to apply, because I am ‘high-risk’. It should be a priority for the government to make both public & private midwifery continuity models widely available for all women of all risk categories who wish to receive an evidence-based best model of care. (ID 320)

Access to mental health support.

A further principle of the Strategy is that women should have access to mental health information, support, and treatment from conception until 12 months after the birth. The findings from the survey demonstrated that perinatal mental health support was difficult to access, as described by these women:

I called EVERY service imaginable for help and some places didn’t even answer the phone. A mental health nurse said that sometimes you just need to ‘give up trying.’ I even went to a mental health ward in (tertiary hospital) to get some help and they just sent me home and said to think happy thoughts. (ID 1210)

Mental health care was the most difficult to access. The very long wait lists to access a GP for a mental health plan and then a very very long waitlist to see a psychologist was… difficult. By the time I saw the psychologist, I was… unwell to the point my husband had to take time off work to look after my baby and I. (ID 147)

Great in theory.

The appropriateness of the Strategy for guiding Australian maternity care was generally acknowledged by respondents, but it was universally agreed that the Strategy had not been well-implemented or translated into practice. The following comments were typical examples relating to this theme:

Great in theory, but health systems and health professionals don’t follow it in the real world. (ID 1744)

It seems a lot of some very nice words… women are being let down, especially in relation to respect and choice. The Strategy doesn’t line up with our birth stats. (ID 927)

Time to raise the bar.

The second theme arising from the general commentary calls on Australian maternity services to elevate the Strategy from a strategic document to an operational policy where women experience transformational maternity care as intended. The following comments illustrate this desire for change:

My experience in the maternity system makes me feel that it is almost luck to receive care that is in line with the maternity care strategy… The Strategy is not widely known by pregnant people and if it were more clearly stated I feel women would be able to know better when they are receiving care that is not in line with it. (ID 1676)

Mums matter! Mental health matters! We are not just incubators. A healthy baby is essential and always the outcome to be aiming for, but it cannot be the only goal of a birth experience. We need to start thinking about how to make this work for the people giving birth so that we are not coming home traumatised and afraid. (ID 733)

It desperately needs to be more transparent, accessible and visible for ALL consumers of maternity care. If we don’t know about what’s available, nothing will change! (ID 712)