Bec Jenkinson

Maternity care providers’ perceptions of women’s autonomy and the law

BackgroundLike all health care consumers, pregnant women have the right to make autonomous decisions about their medical care. However, this right has created confusion for a number of maternity care stakeholders, particularly in situations when a woman’s decision may lead to increased risk of harm to the fetus. Little is known about care providers’ perceptions of this situation, or of their legal accountability for outcomes experienced in pregnancy and birth. This paper examined maternity care providers’ attitudes and beliefs towards women’s right to make autonomous decisions during pregnancy and birth, and the legal responsibility of professionals for maternal and fetal outcomes.MethodsAttitudes and beliefs around women’s autonomy and health professionals’ legal accountability were measured in a sample of 336 midwives and doctors from both public and private health sectors in Queensland, Australia, using a questionnaire available online and in paper format. Student’s t-test was used to compare midwives’ and doctors’ responses.ResultsBoth maternity care professionals demonstrated a poor understanding of their own legal accountability, and the rights of the woman and her fetus. Midwives and doctors believed the final decision should rest with the woman; however, each also believed that the needs of the woman may be overridden for the safety of the fetus. Doctors believed themselves to be ultimately legally accountable for outcomes experienced in pregnancy and birth, despite the legal position that all health care professionals are responsible only for adverse outcomes caused by their own negligent actions. Interprofessional differences were evident, with midwives and doctors significantly differing in their responses on five of the six items.ConclusionsMaternity care professionals inconsistently supported women’s right to autonomous decision making during pregnancy and birth. This finding is further complicated by care providers’ poor understanding of legal accountability for outcomes experienced in pregnancy and birth. The findings of this study support the need for guidelines on decision making in pregnancy and birth for maternity care professionals, and for recognition of interprofessional differences in beliefs around the rights of the woman, her fetus and health professionals in order to facilitate collaborative practice.

Maternity care plans: a retrospective review of a process aiming to support women who decline standard care

BACKGROUND All competent adults have the right to refuse medical treatment. When pregnant women do so, ethical and medico-legal concerns arise and women may face difficulties accessing care. Policies guiding the provision of maternity care in these circumstances are rare and unstudied. One tertiary hospital in Australia has a process for clinicians to plan non-standard maternity care via a Maternity Care Plan (MCP). AIM To review processes and outcomes associated with MCPs from the first three and a half years of the policys implementation. METHODS Retrospective cohort study comprising chart audit, review of demographic data and clinical outcomes, and content analysis of MCPs. FINDINGS MCPs (n=52) were most commonly created when women declined recommended caesareans, preferring vaginal birth after two caesareans (VBAC2, n=23; 44.2%) or vaginal breech birth (n=7, 13.5%) or when women declined continuous intrapartum monitoring for vaginal birth after one caesarean (n=8, 15.4%). Intrapartum care deviated from MCPs in 50% of cases, due to new or worsening clinical indications or changed maternal preferences. Clinical outcomes were reassuring. Most VBAC2 or VBAC>2 (69%) and vaginal breech births (96.3%) were attempted without MCPs, but women with MCPs appeared more likely to birth vaginally (VBAC2 success rate 66.7% with MCP, 17.5% without; vaginal breech birth success rate, 50% with MCP, 32.5% without). CONCLUSIONS MCPs enabled clinicians to provide care outside of hospital policies but were utilised for a narrow range of situations, with significant variation in their application. Further research is needed to understand the experiences of women and clinicians.

Maternity services and the discharge process: A review of practice in Queensland

BACKGROUND Efforts to increase postnatal support available to women and families are hampered by inadequate referral mechanisms. However, the discharge process in maternity services has received little research attention. AIM To review current discharge practices in Queensland, in order to identify mechanisms to minimise fragmentation in the care of women and families as they transition from hospital-based postnatal care to community-based health and other services. METHODS A survey of discharge practices in Queensland hospitals that offer birthing services (N=55) and content analysis of discharge summary forms used by those hospitals. FINDINGS Fifty-two Queensland birthing hospitals participated in the study. Discharge summaries were most commonly sent to General Practitioners (83%), less commonly to Child and Family Health Nurses (CFHNs; 52%) and rarely to other care providers. Discharge summaries were usually disseminated within one week of discharge (87%), but did not capture any information about care provided by domiciliary services. Almost one-fifth (19%) of hospitals did not seek womens consent for the disclosure of their discharge summary and only 10% of hospitals had processes for women to check accuracy. Significant gaps in the content of discharge summaries were identified, particularly in psychosocial and cultural information, and post-discharge advice. The format of discharge summaries diminished their readability. CONCLUSION Discharge summaries (format and content) should be consistent, comprehensive and specific to maternity services. Discharge summaries should be generated and disseminated electronically at the time of discharge from the maternity service. Women should review their discharge summaries and direct and consent to its dissemination.

Primary Maternity Units in rural and remote Australia: Results of a national survey

BACKGROUND Primary Maternity Units (PMUs) offer less expensive and potentially more sustainable maternity care, with comparable or better perinatal outcomes for normal pregnancy and birth than higherlevel units. However, little is known about how these maternity services operate in rural and remote Australia, in regards to location, models of care, service structure, support mechanisms or sustainability. This study aimed to confirm and describe how they operate. DESIGN a descriptive, cross-sectional study was undertaken, utilising a 35-item survey to explore current provision of maternity care in rural and remote PMUs across Australia. Data were subjected to simple descriptive statistics and thematic analysis for free text answers. SETTING AND PARTICIPANTS Only 17 PMUs were identified in rural and remote areas of Australia. All 17 completed the survey. RESULTS the PMUs were, on average, 56km or 49minutes from their referral service and provided care to an average of 59 birthing women per year. Periodic closures or downgrading of services was common. Low-risk eligibility criteria were universally used, but with some variability. Medically-led care was the most widely available model of care. In most PMUs midwives worked shift work involving both nursing and midwifery duties, with minimal uptake of recent midwifery workforce innovations. Perceived enablers of, and threats to, sustainability were reported. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE a small number of PMUs operate in rural Australia, and none in remote areas. Continuing overreliance on local medical support, and under-utilisation of the midwifery workforce constrain the restoration of maternity services to rural and remote Australia.

Is the Birthing Unit Design Spatial Evaluation Tool valid for diverse groups

BACKGROUND Awareness of the impact of the built environment on health care outcomes and experiences has led to efforts to redesign birthing environments. The Birth Unit Design Spatial Evaluation Tool was developed to inform such improvements, but it has only been validated with caseload midwives and women birthing in caseload models of care. AIM To assess the content validity of the tool with four new participant groups: Birth unit midwives, Aboriginal or Torres Strait Islander women; women who had anticipated a vaginal birth after a caesarean; and women from refugee or culturally and linguistically diverse backgrounds. METHODS Participants completed a Likert-scale survey to rate the relevance of The Birth Unit Design Spatial Evaluation Tools 69 items. Item-level content validity and Survey-level validity indices were calculated, with the achievement of validity set at >0.78 and >0.9 respectively. RESULTS Item-level content validity was achieved on 37 items for birth unit midwives (n=10); 35 items for Aboriginal or Torres Strait Islander women (n=6); 33 items for women who had anticipated a vaginal birth after a caesarean (n=6); and 28 items for women from refugee or culturally and linguistically diverse backgrounds (n=20). Survey-level content validity was not demonstrated in any group. CONCLUSION Birth environment design remains significant to women and midwives, but the Birth Unit Design Spatial Evaluation Tool was not validated for these participant groups. Further research is needed, using innovative methodologies to address the subconscious level on which environment may influence experience and to disentangle the influence of confounding factors.