Improving maternity services in Australia: the report of the Maternity Services Review

4. Information and Support for Women and Their Families

Page last updated: February 2009

Current Context

Information and support for women assists them in making decisions at all stages of their pregnancy: prior to becoming pregnant, during pregnancy, birthing and in the postnatal period. These decisions can have short and long‑term impacts on health outcomes for mothers and babies alike. Some women have difficulty accessing evidence-based information about pregnancy, birth and the postnatal period. Furthermore, another important aspect of informed decision making is that perceptions of risk are different for each woman and for each maternity care provider. This adds complexity to the provision of information and support for women.

The need for information and support strategies to address obesity, alcohol and smoking has a particular relevance for pregnancy. Average smoking rates of pregnant women are 17.4 per cent of all pregnancies, 42 per cent during teenage pregnancies, and 52 per cent for Indigenous pregnancies. There is a reported 59 per cent of women drinking at some time during their pregnancy and an increasing prevalence of obesity in young women. These factors pose serious risks to the developmental prospects of affected children and their lifelong health. 74

Similarly, exclusive breastfeeding duration rates are of concern. Australia’s dietary guidelines recommend exclusive breastfeeding of infants until six months of age, with the introduction of solid foods at around six months and continued breastfeeding until the age of 12 months and beyond if both mother and infant wish. The NHMRC considers that an initiation rate for breastfeeding in excess of 90 per cent and a rate of infants being breastfed at age six months of 80 per cent are an achievable goal for Australia. 75 The 2006–07 report of the Longitudinal Study of Australian Children found a breastfeeding initiation rate of 92 per cent, which compares favourably with the NHMRC’s suggested goal. 76 However, the breastfeeding rate declined steadily after birth, with 71 per cent of infants fully breastfed at age one month, 56 per cent at age three months and 14 per cent at age six months. At 12 months, 28 per cent of children were still receiving some breastmilk. Figure 9 shows the percentage of infants receiving full breastmilk and complementary breastmilk (supplemented with other food or drink) to 12 months of age.

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Figure 9: Breastfeeding: the first 12 months

Figure 9: Breastfeeding: the first 12 months

Source: Australian Institute of Family Studies, 2008, Growing up in Australia: the Longitudinal Study of Australian Children: 2006-07 Annual Report, available http://aifs.org.au/growingup/pubs/ar/ar200607/breastfeeding.html



A myriad of factors influence why mothers stop breastfeeding or do not continue to breastfeed exclusively for the first six months. There is a complex relationship between individual-level factors such as the health and risk status of mothers and infants, socioeconomic status, education level, knowledge, attitudes and skills; group-level factors such as home and family environment, support from hospital and health services, workplace flexibility, community attitudes and the public policy environment; and social, cultural and economic factors which affect child feeding and parenting behaviour and the roles of women and men in society. 77

Recently published Australian research investigated the relationship between socioeconomic status and breastfeeding and reported a widening gap in breastfeeding rates between families living in the most advantaged and disadvantaged areas. 78 The relationship between breastfeeding and returning to work is complex. A 2004–05 Australian survey(s) found a relatively small proportion of women returned to work in the early months following childbirth—11 per cent at 3 months, 21 per cent at 6 months and 42 per cent by 12 months—and most of those who returned to work did not work full time. 79 Employment alone did not account for declining breastfeeding in the early months, however; the study found that mothers who were not employed or who worked fewer than 10 hours per week had the highest breastfeeding rates at each of 3, 6, 9 and 12 months. 80 The type of work also mattered, with self-employment and more flexible jobs being associated with higher rates of breastfeeding. 81 A recent Californian study found a positive association between the length of maternity leave taken and the duration of breastfeeding, and that mothers taking shorter maternity leave, working in inflexible or non‑managerial jobs or experiencing psychosocial distress were more likely to stop breastfeeding earlier. 82

Perinatal depression has been identified as a priority by the Commonwealth, state and territory governments given that approximately 15 per cent of new mothers in Australia each year experience perinatal depression.83 Evidence strongly indicates that mothers who have good mental health in the perinatal period have positive impacts upon the cognitive, emotional and behavioural consequences of their children. Children of mothers with perinatal depression have been shown to have increased risk of depression and anxiety disorders.84

Another group requiring particular support are women who experience adverse pregnancy outcomes, including stillbirth. Stillbirth, for example, affects almost one per cent of all births in Australia; 2,091 pregnancies of at least 20 weeks’ gestation ended in a stillbirth in 2006.85 This represents one stillborn baby for every 134 births.

Also important are the links for women between maternity services and those services that will provide ongoing health care for mothers and their babies, particularly primary health care services, including GPs and child health services.

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What the Review Team Heard

  • A range of issues and perspectives were provided to the Review concerning the scope and adequacy of support services available to assist women. These included professional postnatal services as well as professional and peer support services including pregnancy education, pregnancy counselling, depression counselling and support, grief and loss counselling and support, breastfeeding support, early parenting adjustment and child health support.

    Peer support which provides non‑medical support and information over an extended time and professional support are complementary. 86

    Birth is a social and physiological function with biological consequences, and therefore managing the emotional wellbeing of women is paramount to ensuring successful delivery and efficacy of maternity services … There is good evidence that building the availability and utilisation of community and peer support at a national level can lead to improved outcomes for women in the perinatal period. 87

  • The need for more extensive professional postnatal support, specifically in the first 10 days postnatally, was raised with the Review. In particular, a number of submissions suggested the need for greater professional support in initiating and establishing breastfeeding, including greater access to support from midwives, including those trained as lactation consultants.

    The crucial issues of supporting the new mother in the postnatal period really hinge on integrating her into the social and health care networks in the community. 88

  • A particular focus of submissions as well as discussion at the Peer and Social Support Forum was the care and support provided to families whose babies had died before, during or after birth. The need for a more consistent approach to ongoing care through the provision of resource materials and access to support (professional and non-professional) was identified. Highlighted to the Review was the limited adoption of the Perinatal Society of Australia and New Zealand Clinical Practice Guideline for Perinatal Mortality Audit.89

    We lost a baby in traumatic circumstances in early pregnancy and my clearest memory of this is being placed in the maternity ward of the local public hospital alongside mothers who had just given birth … it took me months to recover and grief counselling would have been a very welcome option. 90

  • Submissions advised of the need for evidence-based information to assist consumers in making decisions about their care.

    Looking back, we now realise that during this pregnancy we experienced a lack of information and support in making our own choices. It seems that in order to find information you must track it down yourself, and being first-time parents that information can be very hard to find, especially if you do not know what information you seek. 91

  • Many consumer submissions received by the Review reflected poor communication on the part of hospital staff, particularly obstetricians. This contributed to the dissatisfaction of these women, who described feeling patronised, bullied and coerced and told what to do, rather than being seen as an equal partner in deciding on care options.
  • In this context, there was also discussion throughout the consultation process about differing perceptions of risk, and the fact that many women may place greater importance on factors not taken into account in a biomedical assessment of risk.
  • The lack of evidence relating to effective care for this period was also raised, highlighting the need for evaluation of existing programs and services and targeted research in this area.

    There is little evidence to guide early postnatal care including routine approaches to maternal and infant health assessment; planning for the postnatal period in pregnancy; identification and management of complex psychosocial issues; the impact of early postnatal discharge on maternal and infant health; the value of routine domiciliary visiting; the impact of linkages between acute and primary care services. 92


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Recent Related Initiatives

The House of Representatives Standing Committee on Health and Ageing report on breastfeeding—The Best Start: Report on the Inquiry into the Health Benefits of Breastfeeding—recognised the health benefits of breastfeeding for both babies and mothers in terms of the physiological, nutritional and cognitive aspects of infant development as well as maternal wellbeing.93 The Australian Government response to the inquiry agreed to:

provide national leadership in promoting and supporting breastfeeding by inviting state and territory governments, through the Australian Health Ministers’ Conference, to collaborate on the development and implementation of a National Breastfeeding Strategy.94

It is envisaged that a National Breastfeeding Strategy will provide a framework for priorities and action for promoting and supporting breastfeeding, including areas of cross-jurisdictional responsibility and best practice.

Since taking office in 2007, the Australian Government has committed funds to various initiatives to support breastfeeding:

  • An infrastructure upgrade to the Australian Breastfeeding Association’s Breastfeeding Helpline is providing mothers, their partners and families, including those in rural and remote areas, with access to breastfeeding advice and peer support via a national toll-free number 1800 MUM 2 MUM (1800 686 2 686).
  • The Australian Breastfeeding Association has been contracted to develop increased breastfeeding education opportunities for health professionals (including nurses and midwives) and nationally recognised courses for Breastfeeding Helpline volunteers.
  • An Australian National Infant Feeding Survey will interview a representative sample of families with young babies, provide data on the prevalence and duration of breastfeeding, explore the barriers to initiating and continuing breastfeeding, and collect data on other foods consumed by Australian infants.
  • A qualitative research project will explore attitudes towards, and perceptions of, breastfeeding among mothers, pregnant women, their partners and health professionals.

Through AHMAC, state and territory governments together with the Australian Government have agreed to collaborate on the development of a National Perinatal Depression Initiative to improve the prevention and early detection of antenatal and postnatal depression, and to provide better care, support and treatment for expectant and new mothers experiencing perinatal depression.

The Australian Government has committed $55 million over five years to this national initiative to strengthen service pathways through additional funding under the Access to Allied Psychological Services Initiative, to support the role of beyondblue as a national centre of excellence on perinatal depression, and to contribute to state and territory government screening, workforce training and development and care pathways. In this context, the Perinatal Depression Working Group established to advise AHMAC on a national framework for perinatal depression has agreed on the importance of quality peer support provided through NGOs in supplementing care pathways for women diagnosed with perinatal depression. The working group comprises representatives of all jurisdictions, beyondblue, and consumer and carer representatives.

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Discussion

A number of submissions to the Review and discussions at the forums pointed to the need for objective and readily accessible information on many aspects of pregnancy, including information about best practice in maternity care and the risks and benefits of different interventions. The need to make such information readily available via the internet was also highlighted. In 2006, the National Health Service (NHS) in the United Kingdom launched an NHS- accredited website aimed at providing consumers with objective, detailed information about all aspects of pregnancy, birth and postnatal care and support. The scope for improved telephone support in Australia is discussed below.

The Department of Health and Ageing has recently commissioned breastfeeding research and data collection projects. They will provide information on how and who to communicate with to promote breastfeeding and assist in identifying further research priorities and strategies to increase breastfeeding rates. Given the Review’s findings about contemporary Australian birthing practices, perinatal support mechanisms and inequality of outcomes and access, additional investigation is warranted on the extent to which breastfeeding promotion messages and support mechanisms are effective in reaching women from diverse cultural and socioeconomic backgrounds.

In any approach to improving accessibility of information, the needs of population subgroups in our community, including Indigenous mothers, should not be overlooked. These subgroups may need particular information and support targeting nutrition, smoking and alcohol consumption.

In assisting consumers in making decisions about their maternity care, it is important to provide information regarding the risks associated with those decisions. Informed decision making should consider safety and effectiveness as well as the values and circumstances of individual women.95 However, communication of the risks associated with those decisions is not necessarily straightforward.96 Studies have shown differences between women’s self-rated pregnancy risk and their biomedical risk score. A range of factors can influence women’s perceptions of risk. Importantly, from a woman’s perspective, this can include factors that are not part of a biomedical risk assessment. For Indigenous (and non-Indigenous) women, risk is considered within a framework of cultural and community needs and values.

Risk communication is essential; however, there is no ‘one size fits all’ guideline. Some work has been done on decision support aids in this area.97 One of the key challenges is to develop methods of communicating risks (and choices) to women who are faced with rapid decision making in an acute setting.

Research indicates that peer support is an important element in reducing the likelihood of mental illness; along with professional assistance, it is an effective intervention in reducing symptoms of postpartum depression.98 Evidence indicates that grief can trigger the onset or recurrence of mental disorder and that poor social support is a risk factor for bereavement-related depression.99 In addition, treatment for complicated grief and bereavement-related depression, which includes broader support mechanisms, is more likely to result in a successful outcome for the individual.100

It is clear from the submissions to the Review and the discussion at the Peer and Social Support Forum, in particular, that there are a range of organisations, large and small, involved in the provision of peer and social support services in their communities, in the areas of perinatal depression and grief and loss support. It is also clear from consultations associated with this Review that compassionate and timely support from professionals and peers for women experiencing grief and loss during the perinatal period is considered to be a vital component of a humane system of care.

Also evident from discussions was that these services were not always well integrated with, or well known by, local clinical care providers. It was suggested that a lack of integration between clinical and non-clinical services providing care can lead to fragmentation of care delivery, confusion and dissatisfaction for women, and an increased risk that critical elements in a woman’s care will be overlooked. This would suggest the need for improved quality assurance and triage arrangements to ensure that the right individuals have access to the right sort of support at the right time. The Australian and New Zealand Stillbirth Alliance (recently established through seed funding from the Department of Health and Ageing) includes professional colleges, parent‑based research foundations and support organisations, and data collection agencies. Part of its intended role is to serve as a centralised resource for sharing information, consulting and connecting organisations and individuals.

The Review Team also considered the operation of the National Pregnancy Telephone Counselling Helpline. The helpline is a national (Australia-wide) helpline that operates 24 hours a day, seven days a week; it is staffed by trained counsellors who provide women who are experiencing an unintended pregnancy and/or their partners with non-directive, non-judgmental, independent pregnancy counselling that explores three pregnancy options (raising the child, having the child adopted or termination of the pregnancy). It does not provide referrals to service provider agencies. The helpline also receives calls from women who are seeking general pregnancy information (for the period July–October 2008, 30 per cent of calls were for general information).

One possible approach that could be considered would be to reorient the existing helpline service to provide a broader range of counselling and advice to women during the antenatal period and following the birth of a child. This service could be provided as an additional service, potentially using the National Health Call Centre infrastructure. An expanded service could, in addition to providing advice relating to pregnancy and the demands of a new baby, support triaging and redirection of calls to existing specialist lines, such as the Australian Breastfeeding Association’s 24-hour national helpline as appropriate. The provision of some targeted support for other specialist NGO peer support organisations, such as those providing grief counselling, to enable them to have the capacity to receive and handle telephone referrals from an expanded national line, may be desirable. Underpinning such an arrangement for referral would be agreed protocols and quality assurance arrangements for referrals and the telephone service provided by the NGO.

For those women and their families who experience the death of a baby, it is particularly important that the information and support provided be appropriate and timely. Training and ongoing skill development for all health professionals who care for families following the death of a baby, including those responsible for conducting autopsies, was identified as a crucial element of support and care. The allocation of dedicated spaces and resources within hospital/healthcare settings to allow for privacy and space for counselling and the provision of support to bereaved families is important.

Conclusions

The Review Team concluded that:

  • The need to support women in making informed choices concerning their pregnancy and birthing options is an important issue. Women need to be well informed about the risks to themselves and their babies that their decisions may involve.
  • While support services exist, in some instances they could be better integrated with clear referral protocols.

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Recommendations

  1. That consideration be given to improving the range of birthing and other pregnancy-related information and resources, including those on the internet, that is made available to assist women in informed decision making; with any information materials specifically recognising the needs of population subgroups such as culturally and linguistically diverse communities, women with a disability, Indigenous and teenage mothers.
  2. That consideration be given to the establishment of a single, integrated pregnancy-related telephone support line for consumers, possibly as part of the National Health Call Centre, providing both clinical and non-clinical support services, complemented by triage to a number of existing specialised support services.
  3. That in order to lengthen the duration of breastfeeding, further evaluation be undertaken to identify the health care or community settings in which breastfeeding information and support are most effectively received, with a particular priority on consulting and supporting women from diverse cultural and socioeconomic backgrounds.
  4. That the development of national maternity care guidelines (Recommendation 3 above) consider the Perinatal Society of Australia and New Zealand Clinical Practice Guideline for Perinatal Mortality Audit.