Judith McAra-Couper

Caesarean-section, my body, my choice: The construction of 'informed choice' in relation to intervention in childbirth

The notion of choice, especially of informed choice, is a central tenet of maternity services in most western countries; it also underpins debate about rising rates of intervention that are now a feature of childbirth in many of these countries. Our study investigated the shaping of understanding and practice in relation to these rising rates of intervention in childbirth in the New Zealand context. Critical hermeneutics was used to analyse the data from interviews with nine midwives and obstetricians, and six focus groups with 33 women. This article reports on the notion of choice, which featured prominently in all the interviews. It became clear that women’s choices were strongly influenced and determined by social change, by the gendering of women, and by values such as control, predictability, convenience, the ‘quick fix’ and the normalization of surgery. We argue that the prevailing notion of ‘informed’ choice obscures the structural and social influences on ‘choice’.

Midwifery education in New Zealand: Education, practice and autonomy

New Zealands midwifery education model is intertwined with a practice model which is underpinned by autonomy and partnership. The curriculum prepares students for practice across the scope of midwifery on their own responsibility. While students have formal learning opportunities within educational institutions they spend at least half of their programme learning through authentic work experiences alongside midwives and women. Midwifery educators partner with practising midwives to support students to develop the knowledge, skills and attitudes required to practise midwifery in the New Zealand context. This paper provides an overview of New Zealands midwifery education model and identifies how it is integrated with New Zealands unique midwifery service.

The Sounds of Silence—A Hermeneutic Interpretation of Childbirth Post Excision

Four women who had been excised were interviewed about their experiences of giving birth. Using hermeneutic phenomenology we analyzed their narratives to more fully understand their experiences of childbirth in the context of excision. Childbirth is characterized by silence related to excision. To ensure safe care, increased communication is needed. The onus for opening channels of communication rests with health professionals whose aim is to provide safe, appropriate care to women and their families. In this article we give voice to womens call for sensitive communication that acknowledges their excision and supports them through the challenges it presents for birth.

Enablers and barriers for women with gestational diabetes mellitus to achieve optimal glycaemic control – a qualitative study using the theoretical domains framework

BackgroundGlycaemic target recommendations vary widely between international professional organisations for women with gestational diabetes mellitus (GDM). Some studies have reported women’s experiences of having GDM, but little is known how this relates to their glycaemic targets. The aim of this study was to identify enablers and barriers for women with GDM to achieve optimal glycaemic control.MethodsWomen with GDM were recruited from two large, geographically different, hospitals in New Zealand to participate in a semi-structured interview to explore their views and experiences focusing on enablers and barriers to achieving optimal glycaemic control. Final thematic analysis was performed using the Theoretical Domains Framework.ResultsSixty women participated in the study. Women reported a shift from their initial negative response to accepting their diagnosis but disliked the constant focus on numbers. Enablers and barriers were categorised into ten domains across the three study questions. Enablers included: the ability to attend group teaching sessions with family and hear from women who have had GDM; easy access to a diabetes dietitian with diet recommendations tailored to a woman’s context including ethnic food and financial considerations; free capillary blood glucose (CBG) monitoring equipment, health shuttles to take women to appointments; child care when attending clinic appointments; and being taught CBG testing by a community pharmacist. Barriers included: lack of health information, teaching sessions, consultations, and food diaries in a woman’s first language; long waiting times at clinic appointments; seeing a different health professional every clinic visit; inconsistent advice; no tailored physical activities assessments; not knowing where to access appropriate information on the internet; unsupportive partners, families, and workplaces; and unavailability of social media or support groups for women with GDM. Perceived judgement by others led some women only to share their GDM diagnosis with their partners. This created social isolation.ConclusionWomen with GDM report multiple enablers and barriers to achieving optimal glycaemic control. The findings of this study may assist health professionals and diabetes in pregnancy services to improve their care for women with GDM and support them to achieve optimal glycaemic control.

A Successful Midwifery Model for a High Deprivation Community in New Zealand: A Mixed Methods Study

In August 2011, the Ministry of Health (MOH) commissioned a report to provide information, evidence, and analysis regarding an integrated lead maternity care model for a midwifery practice situated in Counties Manukau, New Zealand, a high deprivation area. The final report was entitled “A Successful Lead Maternity Care Midwifery Practice in Counties Manukau” (Priday & McAra-Couper, 2011). The project was both qualitative (qualitative descriptive) and quantitative (descriptive statistics) in its review and audit of the Midwifery Practice. The midwives from this practice have been providing continuity of midwifery care for 17 years, and the MOH was interested in how this group of midwives (“the Midwifery Practice”) was working and the implications of this style of practice. The report demonstrated that the Midwifery Practice provides continuity of care for predominantly Pacific and Maori (indigenous) women and young women, including adolescents. The socioeconomic indicators of these women place them in the high deprivation index group. Given these three factors—ethnicity, age, and deprivation decile—high perinatal mortality and other adverse outcomes could be expected. However, statistics demonstrate low perinatal mortality and morbidity, with most women booking for care before 20 weeks’ gestation and recording optimal birth outcomes. The Midwifery Practice is integrated into the community facilitating a connected and accessible service for women and families. These findings are significant in light of the repeated call from the Perinatal and Maternal Mortality Review Committee (PMMRC, 2013), urging stakeholders who provide health and social services to identify the reasons why women are failing to engage with care and to identify interventions to address barriers. This article summarizes the findings from the report.

Staying Involved “Because the Need Seems So Huge”: Midwives Working With Women Living in Areas of High Deprivation

The aim of this research was to answer the research question “what is the midwifery care provided by midwives to women living in areas of high deprivation?” It has been identified that rates of stillbirth and neonatal death are significantly higher in women living in the most socioeconomically deprived areas of New Zealand. A potential contributory factor to these rates is the issue of access to, and engagement with, maternity services. Yet, little is known about the care midwives provide to women living in areas of socioeconomic deprivation. Using grounded theory methodology, a conceptual framework was developed from data analysis of 8 interviews undertaken with midwives between August 2000 and March 2001. Findings revealed a core category of “staying involved `because the need seems so huge.”’ Four further categories were identified: “Forming relationships with the wary,” “Giving `an awful lot of support,”’ “Remaining close by,” and “Ensuring personal coping.” Throughout, the midwives’ continued involvement with the woman ensured an optimal pregnancy outcome for both the woman and her new baby. The findings from this study inform the care provided by midwives who work with women living in areas of high deprivation and begin to address factors regarding access to, and engagement with, maternity services.

A cross-country survey of attitudes toward childbirth technologies and interventions among university students

PROBLEM & AIM Cultural beliefs that equate birth technology with progress, safety and convenience contribute to widespread acceptance of childbirth technology and interventions. Little is known about attitudes towards childbirth technology and interventions among the next generation of maternity care users and whether attitudes vary by country, age, gender, childbirth fear, and other factors. METHODS Data were collected via online survey in eight countries. Students who had never had children, and who planned to have at least one child were eligible to participate. FINDINGS The majority of participants (n=4569) were women (79.3%), and the median age was 22 years. More than half of students agreed that birth technology makes birth easier (55.8%), protects babies from harm (49.1%) and that women have a right to choose a medically non-indicated cesarean (50.8%). Respondents who had greater acceptance of childbirth technology and interventions were from countries with higher national caesarean birth rates, reported higher levels of childbirth fear, and were more likely to report that visual media or school-based education shaped their attitudes toward birth. Positive attitudes toward childbirth technology and interventions were also associated with less confidence in knowledge of birth, and more common among younger and male respondents. DISCUSSION/CONCLUSION Educational strategies to teach university students about pregnancy and birth in ways that does not frighten them and promotes critical reflection about childbirth technology are needed. This is especially true in countries with high rates of interventions that reciprocally shape culture norms, attitudes, and expectations.

Pasifika women's choice of birthplace

A Corresponding Author: jmcaraco@ aut.ac.nz B Auckland University of Technology, Auckland C Midwife, Auckland Background: Birth is a socially constructed experience for Pasifika living in New Zealand that is shaped by their community and maternity provider’s influences. Pasifika women in the Counties Manukau region predominantly choose to birth in a tertiary facility despite there being primary facilities available. Aim: This study asked Pasifika women about their choices for place of birth within the Counties Manukau District Health Board region. Method: Six healthy, low risk Pasifika women, who had given birth in the Counties Manukau District Health Board region, participated in this study. All women were interviewed individually and conversations were analysed using thematic analysis, followed by a hermeneutic interpretation. Findings: The women shared a culture of “we birth at Middlemore [Hospital] and that is where you have babies”. Their data surprised us as researchers. Those who had been transferred postnatally to primary units tended to still prefer Middlemore. We use the word “prejudice” in recognising that we thought (backed by research evidence) that they would be more likely to have a normal birth in a primary unit, and would prefer that experience. They told us that Middlemore Hospital was close to home; it was a place they knew; and it was where they preferred to give birth. The Pasifika women’s understanding of choice of birthplace was influenced by their community and, perhaps, by their midwife. While they seemed to have minimal understanding of why they would choose to birth at a primary birthing unit, there was a sense that even if they had this knowledge, they would not have changed their minds. They had a trust of, and familiarity with, Middlemore Hospital that held firm. They had their prejudice; we had ours. Recognising these different views offers a different space for conversation. Conclusion: It is important that any new or re-designed birthing unit be planned in collaboration with Pasifika women if it is intended for their use. Further, it is important that midwives take the time to listen to Pasifika women, and those from other cultures, to understand their point of view.

Risk of perinatal mortality in the first year of midwifery practice in New Zealand: analysis of a retrospective national cohort

Objectives To determine whether there was an increased risk of perinatal mortality among mothers booked for care with community lead maternity carer (LMC) midwives in their first compared with later years of practice. Design Retrospective cohort study using linked national maternity, mortality and workforce data; adjusted analysis using logistic regression. Setting New Zealand. Participants Women under community LMC midwifery care birthing 2008–2014. Main outcome measures Perinatal mortality (stillbirths and neonatal deaths of babies born from 20 weeks’ gestation to the 27th day of postnatal life), excluding terminations and deaths associated with congenital abnormalities. Results There were 2045 deaths among 344 910 births booked with midwives. First year of practice midwives cared for women with higher risk of perinatal mortality, including Māori, Pacific, Indian, <20-year-old mothers, nullipara, smokers, women living in socioeconomic deprivation and with high body mass index, than midwives beyond first year of practice. There was a significant reduction in unadjusted odds of perinatal mortality among women under the care of midwives beyond the first year compared with those within the first year (OR 0.79, 95% CI 0.67 to 0.93) but no significant reduction in risk remained after adjusting for known risk factors, (OR 0.89, 95% CI 0.74 to 1.07). There was a significant increase in the adjusted odds of perinatal mortality among midwives booking a caseload of 15 or fewer mothers per year (1.34, 1.01 to 1.78) and 16 to 30 (1.25, 1.04 to 1.50) compared with midwives booking 51 to 80. Conclusions Findings suggest that the first year of midwifery practice is not associated with an increased risk of perinatal mortality but there is evidence that early career midwives are caring for higher-risk women. These findings suggest inequity of access for higher-risk women to experienced midwives and highlight an opportunity to improve support for vulnerable women and new midwives.