Ellen O'Keeffee - Safe Motherhood for All

Something to Ponder
‘A woman’s relationship with her maternity
providers is vitally important. Not only are these
encounters the vehicle for essential lifesaving
health services, but women’s experiences with
caregivers can empower and comfort or inflict
lasting damage and emotional trauma. Either
way, women’s memories of their childbearing
experiences stay with them for a lifetime and are
often shared with other women, contributing to
a climate of confidence or doubt around
childbearing.’ White Ribbon Alliance, Respectful Maternity Care, 2011

Listening to Women
healthy women healthy families healthy nations

Acknowledgment of Country
I would like to acknowledge the Wurundjeri
people of the Kulin Nation people as the
traditional owners and custodians of the land on
which we meet today.
I especially acknowledge the women who have
birthed their babies, and the men and women
who have raised their families, on this country.

The Mother’s Tale
Women’s Experiences of Birth Care in Australia
The Birth Dignity Survey 2017
Twitter - @SMFA_au
#respectfulmaternity

The Distinctive Importance
of the Childbearing Period
Childbearing is an important rite
of passage, with deep personal
and cultural significance for a
woman and her family.
http://whiteribbonalliance.org/campaigns2/respectful-maternity-care
Twitter - @SMFA_au

Safe Motherhood
• The concept of “safe motherhood” is usually
restricted to physical safety at birth.
• Cultural, emotional, social, psychological and
spiritual safety rarely appear in the
discussions.
(Lock, 2014) & (Dahlen 2015).
Twitter - @SMFA_au

A positive birth experience
Research has consistently shown that two of the
most important factors in ensuring positive
experiences of childbirth are:
• the provider’s provision of care in supportive
relationships; and
• the woman’s experience of care and sense of
control over decisions made during birth.
(Waldenström, 2004; Stadlmayr, 2006)
(WHO 2015)
Twitter - @SMFA_au

The Birth Dignity Survey
• Over 1,735 women responded.
• The questions focused on choice and
respect.
• Our results reveal that many women still do
not receive respectful care or choice in
childbirth.
Twitter - @SMFA_au

Methodology
• Safe Motherhood for All Inc. hosted a
survey about women’s experiences of
childbirth.
• The survey was open to any woman who
had given birth in the past 2 years.
• Women self-selected to undertake the
survey.
Twitter - @SMFA_au

Ethical Considerations
• All respondents self selected
• The tool had been used previously
• All respondents were able to provide
their contact details for further follow-
up.
• Respondents who requested contact
were offered counselling services.
Twitter - @SMFA_au

The survey sample
1,735 women completed the survey.
• 46.34% of respondents were first-time
mothers
• 52.39% were second-time or more mothers.
• 98.56% of births were of a single infant.
• 67.88% received public maternity care.
Twitter - @SMFA_au

The survey sample
• 30.33%preferred not to specify their ethnic
origin.
• Of those who did 89% of respondents
identified as Australian/Caucasian/Anglo
Saxon.
• 11% identified as Asian, African, Middle
Eastern, European, Indian, Maori or Pacific
Islander.
Twitter - @SMFA_au

Respondents by State or Territory
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Regional spread of respondents
Twitter - @SMFA_au

Type of Birth
Twitter - @SMFA_au

Place of Birth
• 72.46% gave birth in hospital,
• 13.63% in a birth centre, either stand-alone or
an alongside unit, and
• 11.55% gave birth in their own home.
Twitter - @SMFA_au

Primary Care Provider
“During the birth, a midwife. During pregnancy I
had appointments with the obstetrician on duty
in the public system.”
“While my primary carer was an obstetrician, my
birth wouldn't have been such a positive
experience without the midwives I had helping
me.”
Twitter - @SMFA_au

Primary Care Provider
• “No idea, I saw a mix of all of them.”
• “I don't even know.”
• “Didn't appear to be anyone at all.”
• “None.”
• “All of them, and no one in particular,
unfortunately.”
• “Me - no one medical person in particular.”
• “Doula.”

Manifestations of mistreatment of
women during childbirth in Australia
This presentation uses Bohren typologies to
describe the types of mistreatment
experienced by women during childbirth, and
the perceived drivers of this mistreatment in
Australia.
Twitter - @SMFA_au

Manifestations of mistreatment of
women during childbirth in Australia
Third order themes Second order themes
Physical abuse  Use of force
 Physical restraint
Sexual abuse  Sexual abuse
Verbal abuse  Harsh language
 Threats and blaming
Stigma and discrimination  Discrimination based on ethnicity,
socioeconomic status and medical condition
Failure to meet professional
standards of care
 Lack of informed consent for procedures
 Neglect and abandonment
 Lack of confidentiality and privacy
Poor rapport between women
and health providers
 Lack of autonomy
 Detainment
 Ineffective communication
Health system conditions an
constraints
 Lack of resources
 Facility culture
 Corruption/bribery

Physical Abuse - Use of force
• “The damage (denial of dignity, waters broken forcefully,
syntocinon IV and continuous foetal monitoring, no regard
for my consent for any of this) had been done.”
• “It took 9 attempts to break waters after asking the
midwife to stop as I had felt it break already. Baby had
multiple lacerations to the head. Very unimpressed with
this unnecessary and painful procedure.”
• “I didn't have a choice about being examined and it hurt
like hell during a contraction. I then couldn't change
positions as the contractions were too intense and I
couldn't move.” Twitter - @SMFA_au

Physical Abuse - Physical restraint
• Multiple reports of being tied to a CTG machine.
• “To be made to labour on my back with a posterior
baby and with back labour just shouldn't happen.”
Twitter - @SMFA_au

Sexual abuse
• “Can you help me make a complaint? It is too hard
and I need women to stop being raped in hospital”
• “I felt medically raped during the after birth of my
twins. This was extremely traumatic at the time
and ongoing.”
Twitter - @SMFA_au

Verbal abuse
• “To top it all off, a doctor swore at me when a small
bit of my blood splattered on his face.”
• “What about when you are surrounded by medical
professionals who are scaring you about your birth--
telling you that if you don’t choose this then your
baby is going to end up injured or dead. “
• “The doctor was rough, spoke aggressively and was
not encouraging at all. She gave me strict time lines
I needed to meet (You need to be dilated by a certain
time; your contractions need to get better etc.).”
Twitter - @SMFA_au

Impact of Disrespect and Abuse
• “My decision to decline medical care before,
during and after my daughter's birth was
influenced by a previous negative, injurious
experience in hospital.”
• “I lost 2.5L of blood and almost died due to
unnecessary interventions and lack of knowledge.
I am planning a drug free home birth for my next
baby. It is the only way I feel I won't be
traumatised again.”
Twitter - @SMFA_au

Stigma and discrimination
• “I weighed 90kg at full term. I feel that the
obstetrician interfered because of my weight not
because it was necessary.”
• “Lack of cultural competency with health
professionals.”
• “I have bipolar disorder. The midwives bullied me
immediately following birth not to BF and told me
that I would harm my baby if I did.”
Twitter - @SMFA_au

Failure to meet professional
standards of care
 Lack of informed consent for physical
examination and procedures
 Lack of confidentiality and privacy
 Neglect and abandonment
Twitter - @SMFA_au

Informed Consent
• All legally competent adults can consent to
or refuse medical treatment.
• Under the law of trespass, patients have a
right not be subjected to an invasive
procedure without consent.
Twitter - @SMFA_au

Informed Consent
10.68% of respondents considered that they had
not given their consent to examinations or
procedures.
11.16% of respondents overall considered that
they had not been given information about each
examination or procedure before it had been
performed.
Twitter - @SMFA_au

I was asked if I agreed to each
examination or procedure before it
took place (by place of birth)
Twitter - @SMFA_au
2.90%
12.04%
Birth Centre
Hospital
Disagree

Lack of informed consent
• “My birth was induced- I did not want this and did
not feel I could discuss my options or say no.”
• “I felt I was only given one option. Everything was
explained but no alternatives were given. One
must be informed of all options to give consent.”
• “I was told, not asked.”
• “To an extent - the information provided was
limited and skewed toward how he wanted the
birth to proceed.”

Lack of Informed Consent
I was asked if I agreed to each examination or
procedure before it took place (by type of
birth)
Twitter - @SMFA_au
8.12%
17.27%
13.58%
Vaginal
Instrumental
Caesarean
Disagree

Confidentiality and Privacy
Privacy is a fundamental aspect of respectful
care.
86.4% of respondents felt their privacy was
respected.
Twitter - @SMFA_au

Lack of confidentiality and privacy
• “I heard doctors talking very loudly outside my room,
saying I was another 'irresponsible mother‘.”
• “But I still feel like I had no privacy, lots of people
came and went and asked questions during
contractions.”
• It felt like every person in the hospital had their hands
inside me and many didn't even speak to me.
• Not given the option of declining students at my birth.

Neglect and abandonment
• “I was made to wait 6 hours for surgery.”
• “I felt fear, terror and completely
disregarded as a human being during my
labour of my first and only child. I did not
know if I was going to be alive to meet my
baby it was that bad.”

A woman’s voice
“I was booked in and told I had to have
syntocinon and that the baby was at risk,
then left alone for four hours while in
transition and active labour.
I felt powerless and very frightened,
thinking that things were going wrong
but with no one to ask.”
Twitter - @SMFA_au

Poor rapport between
women and health
providers
• Lack of autonomy
• Detainment
• Ineffective communication
Twitter - @SMFA_au

Autonomy
I had the birth I wanted.
• 58.25% agreed
• more than a quarter - 27.1% disagreed
• 13.02% neither agreed nor disagreed.
Twitter - @SMFA_au

Lack of Autonomy
• 35.65% of respondents did not have a choice
about where to give birth.
• 15.05% of respondents were not given
adequate information by their maternity care
provider about their choices about their birth.
Twitter - @SMFA_au

A woman’s voice
“Being my first pregnancy and birth. I feel I
wasn’t aware of my options and now being
pregnant with my second baby, using a
different hospital and type of care I can see
a number of flaws in my first birth
experience. I suppose knowledge and
confidence is key for a labouring mother,
this I lacked at the time.”
Twitter - @SMFA_au

Autonomy –
Choice of position in labour
66.88% of respondents overall were happy with
the choice of position in labour.
This figure was significantly higher (97.02%) in
birth centres than in hospitals (75.27%).
Twitter - @SMFA_au

A woman’s voice
“When the experienced midwife entered
she was very helpful. She was amazing and
helped me to change positions when I
wanted to, while other less experienced
midwives had previously encouraged me to
stay on my back which was very difficult for
me and I believe this was the reason for
slow progress. “
Twitter - @SMFA_au

Autonomy - Control in childbirth
Research has shown that feeling in control
during childbirth is associated with positive
feelings about birth experiences
(Gibbins and Thomson 2001; Waldenstöm 2004).
“A lot of choices and control was removed for
me.”
Twitter - @SMFA_au

A woman’s voice
“I am a very strong willed, well informed
person. I have no doubt that had I not been
so, I would have experienced interventions
simply because they are part of hospital
protocol (ie internal examinations).”
Twitter - @SMFA_au

Lack of Autonomy
“Because I was a VBAC, I felt the hospital
midwives and doctors were just '
managing' their own fears about VBAC
and ignored my rights altogether. I had
already had a vaginal birth after my
caesarean but they just fixated on me
being a VBAC and acted entirely in their
own interests and not mine.”Twitter - @SMFA_au

Lack of Autonomy
• “Throughout most of the experience I felt I
had to fight for my (and my baby's) rights,
advocate for my choices by justifying myself
based on evidence based research & fight
against fear based advice & coercion.”
• A lot of our wishes were met with resistance
and really inconsiderate reasoning.
Twitter - @SMFA_au

Effective communication
• The majority of women (87.75%) reported
that healthcare professionals spoke to them in
a kind and friendly way.
• Asked whether healthcare professionals
listened to them, 80% of respondents agreed
that they did.
Twitter - @SMFA_au

Ineffective communication
• “I was not listened to and my individual
circumstances were not considered.”
• “Felt very scared leading up to birth because no
one seemed to listen or take my concerns or
queries seriously.”
• “The post-natal ward doctors ignored every
request I made and told me to talk to my GP about
an iron infusion.”
Twitter - @SMFA_au

System conditions & constraints
• Lack of resources
• Facility culture
• Corruption/bribery

Lack of resources
• “I felt let down my medical professionals, being juggled
between teams, no one person taking responsibility,
being tossed aside cause there wasn't enough staff to
facilitate my labour, husband left to clean up after midwife
broke my waters.”
• “The midwife I had was looking after 2 labouring women
and was often not in the room. This is where my doula
and husband were my main support.”
• “Was told I had to get a c-section because they were
understaffed!!!!”

Facility culture
• “It wasn't a particular health professional that let me down
more so the system and lack of staffing. I was no one’s patient
and therefore no one felt responsible for me which led to a
lack of care and a traumatic birth experience that wasn't even
followed up on (no debrief, postnatal mental survey nor a
complete health record - like bub and I did not even exist).”
• “It was never made clear that policies are not law.”
• “Attitudes of the hospital admin/management staff were
controlling which impacted on my experience as well as the
capabilities of my chosen health professionals to honour my
preferences.”
Twitter - @SMFA_au

Respectful Maternity
Care
An approach focusing on factors that
support human health and well-being:
• Care that does no harm
• Care that is culturally sensitive,
valued by the woman and her
community
Twitter - @SMFA_au

Respectful care
Did you feel respected by midwives and other
medical staff?
84.72% of respondents felt respected.
Twitter - @SMFA_au

Respectful care
• “My midwife only ever gave her opinion if directly
asked, & respected our wishes even when they
differed to hers.”
• “I had the most incredible, respectful and
empowering labour. I owe so much to my midwives.”
• “I was fortunate to receive a low intervention
approach, with decisions made to intervene carefully
and respectfully.”
• “My Public system births were all amazing. The midwives
and doctors I saw were respectful and great. They read
my 'birth preferences' before they saw me.”
Twitter - @SMFA_au

Respectful care
Did you feel respected by midwives and other
medical staff?
15.28% of respondents disagreed.
“I was not listened to and my individual circumstances
were not considered.”
Twitter - @SMFA_au

Disrespectful care
“When I was being repaired after a third
degree tear, the Dr refused to take me to
theatre. I didn't have any pain relief, I could
feel what he was doing and he wouldn't stop.
He was too busy teaching, it was
embarrassing to have two men sitting
between my legs staring at me. I felt so
violated. I didn't know what was happening, I
didn't realise the effect this would have on
me, I have anxiety now and haven't had sex
for almost three years.”
Twitter - @SMFA_au

Disrespectful care
“I will never forgive myself for not listening to my
intuition and not standing up for myself and my
baby and caving to medical pressure.
The cruel irony is that I wanted to have a home
birth. Due to family pressure I decided to go to the
birth centre in case anything should arise.
Little did I know that that almost guarantees
some sort of pressure to intervene in my
circumstances.”

Disrespectful care
“I felt not listened to, and that I was
being dramatic.
This baby was my 7th birth, I knew my
body and how it works through the
birthing process.
I tried to be as informative as possible
to ensure the best care for myself and
my baby, to which was disregarded.”

How did your experience of childbirth
affect your feelings about yourself?
(By type of birth)
Twitter - @SMFA_au
79.81%
40.85%
27.22%
11.11%
42.96%
55.35%
Vaginal
Instrumental
Caesarean
Positive
Negative

How did your experience of childbirth
affect your feelings about yourself?
(By place of birth)
Twitter - @SMFA_au
91.38%
55.16%
3.45%
30.49%
Birth
Centre
Hospital
Positive
Negative

Birth impact on the woman’s
relationship with her baby
• 61% of women felt that the birth affected their
relationship with their baby.
• 12.76% felt the impact was negative.
People said ‘at least you have a healthy baby though’.
Yes I did have a healthy baby.
However he deserved so much more.
He deserved a healthy mother.
Twitter - @SMFA_au

A woman’s voice
“People said ‘at least you have a
healthy baby though’.
Yes I did have a healthy baby.
However he deserved so much
more.
He deserved a healthy mother.”
Twitter - @SMFA_au

A woman’s voice
“My negativity in regards to my birth experience
comes from the cascade of intervention I
endured following an induction, resulting in a
very scary and prolonged labour which was
traumatic for myself and my husband.
I felt very anxious and scared following the birth
of my baby and believe this affected our initial
bond.”
Twitter - @SMFA_au

Birth impact on the woman’s
relationship with her partner
• 14.5% of respondents overall felt childbirth
had a negative impact.
Twitter - @SMFA_au

Desire to have more children
62. 66% felt that their birth experience led to
positive feelings about having children in the
future,
28.53% felt it had a negative impact.
Twitter - @SMFA_au

Home birth
There were higher levels of satisfaction with
home birth care.
For example, of those women who reported an
effect on their relationship with their baby, 97%
of respondents who gave birth at home felt the
birth experience had a positive effect.
96% of respondents felt in control of their birth
experience at home.
Twitter - @SMFA_au

In Summary
The Birth Dignity Survey paints a mixed picture
of maternity care in Australia.
Twitter - @SMFA_au

Where to from here?
Provide care that:
Reflects The World Health Organisation’s
framework for quality of care for pregnant
women and newborns.
Honours the National Safety and Quality Health
Care Standards that require respect for patient
rights and engagement in their care.
Is informed by The Respectful Maternity Care -
The Universal Rights of Childbearing Women.
Twitter - @SMFA_au

In Conclusion
All health professionals have a
role in ensuring that they
provide evidence based
respectful care and that the
women they care for are
empowered to be equal
partners in this processhttp://www.un.org/press/en/2011/gashc4009.doc.htm

In Conclusion
True dignity in care includes:
• deference to women at each step of
the way;
• fully informed consent; and
• support instead of coercion or
pressure about their decisions.
Respect in Birth: Get over Yourselves https://improvingbirth.org/2013/02/respect-in-birth-get-over-yourselves-2
Twitter - @SMFA_au

We need to remember and respect
that pregnancy & birth for a woman is
more than an everyday medical event.
We need to put in place responsive,
sensitive maternity care systems that
cater for the individual.
We need to rediscover pregnancy and
birth as a family joy not as an illness
to be treated. Twitter - @SMFA_au

Ellen O'Keeffee - Safe Motherhood for All

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