Submission to:
Standing Committee on Health, Ageing and Community Services
Email: LACommitteeHACS@parliament.act.gov.au 

Submission to the Standing Committee on Health, Ageing and Community Services: Inquiry into Maternity Services in the ACT

Women’s Centre for Health Matters Inc.

January 2019

The Women’s Centre for Health Matters acknowledges that the Australian Capital Territory is Ngunnawal Country, and acknowledges the Ngunnawal people as the traditional owners and continuing custodians of the lands of the ACT, and we pay our respects to the Elders, families and ancestors.

Submission to the Standing Committee on Health, Ageing and Community Services: Inquiry into Maternity Services in the ACT.

Women’s Centre for Health Matters Inc.
January 2019

Enquiries on this submission may be directed to:
Chief Executive Officer: Marcia Williams
ceo@wchm.org.au 

PO Box 385, Mawson, ACT, 2607
Phone (02) 6290 2166
Facsimile (02) 6286 4742
admin@wchm.org.au 
www.wchm.org.au 
Introduction
The Women’s Centre for Health Matters Inc. (WCHM) is a community-based not for profit organisation which works in the ACT and surrounding region to improve women’s health and wellbeing.
WCHM believes that health is determined not only by biological factors, but also by a broad range of social, environmental and economic factors known as the ‘social determinants of health’. We acknowledge that the environment and life circumstances that each woman experiences have a direct impact on her health, and in many cases, women’s poor health is rooted in social disadvantage. 
WCHM aims to promote women’s health by working to ensure that women can contribute to and are aware of the health choices available to them. We want women to feel in control of and understand the determinants of their own health and wellbeing.
We do this in a variety of ways including by: health promotion, social research with women in the ACT and surrounding region, advocacy, working across sectors, community development, capacity building, and health and wellbeing information provision and education to:
•	Provide women with access to reliable and broad ranging health-related information which allows informed choices to be made about each woman’s own health and wellbeing; and 
•	Advocate to influence change in health-related services and policy to ensure responsiveness to women’s needs and emerging issues.
WCHM is committed to taking a whole-of-life and social approach to women's health that is also firmly situated within a human rights framework. 
WCHM focuses where possible on groups of women who experience disadvantage, social isolation and marginalisation (women with disabilities, institutionalised women, women living with mental health issues, women from culturally and linguistically diverse backgrounds (CALD), and older women); and on emerging issues impacting on women in the ACT and the surrounding region.

Response to the Inquiry into Maternity Services in the ACT
As an organisation that works to make the views of women known, WCHM welcomes the opportunity to provide a submission to the Committee on the Inquiry into Maternity Services in the ACT, given the Centre’s work in exploring women’s views and influencing ACT responses to the provision of maternity services over the last few years. 
In writing this submission WCHM has chosen to limit its comments to those areas in the Terms Of Reference where it has the most knowledge - the preferences, views and concerns of ACT women. We have supported our responses with evidence gathered and/or published by the Centre on the needs of women living in the ACT and surrounding region, and also from the input from partners who work with women in the ACT.  

The Terms of Reference (TOR) set out six key areas of focus in preparation for development of policy and actions, and we have chosen to respond with particular reference to:
A.  Models of care for all maternity services offered at the Centenary Hospital for Women and Children (CHWC) and Calvary Public Hospital (CPH), including, but not limited to, the Birth Centre, the Canberra Midwifery Program, and the Home Birth Trial and whether there are any gaps in care;
D. Management of patient birthing preferences, including, but not limited to, professional advice offered to patients, and the practices associated with birthing emergencies;
H Patient satisfaction with the services;
L Any related matters.

These are the issues about which WCHM is able to provide advice, based on our consultations with ACT women, and the advice of our partners.

INTRODUCTION
Last year in the ACT, over 6,400 women gave birth, so maternity care is an important part of ACT’s provision of health services.  For WCHM, maternal care covers providing advice, checking on the wellbeing of a woman and her baby and the provision of women centred care and support - from prenatal and antenatal care during pregnancy, to care during labour and birth, to postnatal care after birth. 
In late 2015 WCHM conducted a consultation project to explore women’s experience of accessing maternal care in the ACT, to collect the stories from women about their experiences, to inform how well the current levels of care meet the needs of women in the Canberra community, and to explore where there might be opportunities to improve local responses.  (Note that during 2012 – 2014 the Centenary Hospital for Women and Children had been opened in stages as a purpose-built facility which co-located ACT Health services such as maternity services, the neonatal intensive care unit, gynaecology and foetal medicine, the birth centre and specialised outpatient services).
The final report was published in May 2016 and it summarised the results of the consultation and provided the feedback and narratives of 171 women who had given birth for the first time in the ACT or Queanbeyan, since August 2013.   Women told us about their experiences of 3 key areas of maternity care – pregnancy, giving birth and post-natal care. The report can be accessed online at http://www.wchm.org.au/women-maternal-care-act-consultation-report/. 
Since that time there have been changes to the delivery of maternity services in the ACT, at the same time as an increase in demand on the maternity services.  And to address the issues raised by women in the report about the need for better information, WCHM developed the Having A Baby In Canberra website which provides a centralised source of local ACT information for women (and their partners and families) and helps women to make informed decisions and choices at all stages of their pregnancy. It was launched on 4th September 2017 and has attracted over 14,000 visits from 1 December 2017 to 30 November 2018.  The website is available at http://www.havingababyincanberra.org.au/
More recently in late 2018, WCHM explored the views of smaller groups of ACT women through focus groups about their understanding of the models of care for maternity in the ACT and what they mean, their experience of finding out about their options, and their feedback about their experiences of maternity. We also sought the views of services working with women post birth in the community.
Although this inquiry is about the provision of maternity services, it is very clear from our consultations that women’s health and wellbeing can be impacted on by the way they experience maternity services. An important element from both the 2015 and 2018 consultations with women has been the importance that women placed on their experience of the care they received.  Women told us how they wanted a positive pregnancy and birth experience and stressed the importance of women’s views being at the centre of maternity care, so that their experience of pregnancy and birthing was positive and so that their babies had the best possible start in life.  
Women also identified continuity of care as an important aspect of having a baby.  We heard that the postnatal period was an extremely important time to promote health and wellbeing for both the mother and baby, and that the continuity of care and supports needed to be available outside of the hospital system in the postnatal period and provided in locally accessible places for women both prior to and after the birth. Of special mention by many women was the importance of breastfeeding support and mental health support.
Well-resourced continuity of care and additional support in the postnatal care system, including providing breastfeeding and mental health supports, provide long term social and health benefits as well as savings in the clinical health system t(such as shorter hospital stays post birth, and reductions in readmissions to hospital and other entry points of the health system).

SUBMISSION
A.  Models of care for all maternity services offered at the Centenary Hospital for Women and Children (CHWC) and Calvary Public Hospital (CPH), including, but not limited to, the Birth Centre, the Canberra Midwifery Program, and the Home Birth Trial and whether there are any gaps in care.
Decision making about where to birth
In our 2015-16 consultations with women, 52 % of respondents birthed at the Centenary Hospital for Women and Children (4 of whom accessed the Birth Centre facilities located within the Centenary Hospital for Women and Children), 26% accessed the public services provided by Calvary Health Care ACT public hospital, 12% birthed at Calvary John James private hospital and 7% birthed at the Queanbeyan Hospital.  Three respondents had participated in a planned home birth and 1 respondent birthed at Calvary Health Care ACT private hospital. 
Participants were asked what information they received about models of care during their pregnancy. With the exception of 8 women who received no information, 110 women reported that they received some information about some of the models of care available in the ACT. The main information provided related to midwife led care, closely followed by General Practitioner Shared Care. 
While at that time, many women made reference to the models of care as having a large influence in their decision making about where to birth their child, the most common reason identified by 33% of the women for the choice of where to birth was the proximity to their home. 
The models of care were identified by 25% of the women who responded as having an influence in their decision making about where to birth their child. Of particular note, was the midwifery led care through the Continuity at Centenary Hospital (CatCH) program and the model of care provided by the Canberra Midwifery Program. The Birth Centre was also highlighted as being a preference for some women because of the values and philosophy behind the care - low intervention and more homelike. Access to water births was also a consideration for some women. (Note: While only one respondent referred to the Birth Centre program at Calvary Hospital, it officially began towards the end of the period that the consultation was targeting.)
Women said: 
We wanted to be a part of the Canberra Midwifery Program - which we got into. 

I wanted an intervention free natural birth with a good continuity of care model.  I also wanted the option of a water birth if that is how I felt on the day.

The birth centre where I had the same midwife the whole way.

Ability to access Birth Centre with the same midwife care before and after birth.

I went through the Birth Centre at Canberra Hospital as I wanted their continuity of care program so that I could have the same midwife all the way through my pregnancy.

I wanted to go through the Birth Centre because of low intervention and continuity of care.

It offered the CatCH program and an option for water births.

Other reasons that were quoted by women as influencing their decision of where to birth were cost and affordability, that their obstetrician delivered there, family and peer recommendations, and the length of hospital stay post delivery.
Women said: 

I wanted public hospital care (affordability).

Could not afford private health care.

…..we couldn’t afford to go private.

My GP recommended my OB and Calvary JJ is the only hospital that my OB delivers at.

Being an older mum I was scared of complications so I wanted to see my own obstetrician.

Family and friends had birthed there with good experiences.

Great feedback from other mums. 

I have had many friends give birth at this hospital and they had a wonderful experience.

I wanted to stay in hospital as long as possible after having my baby and the public system did not provide this opportunity.

I wanted a longer length of stay post birth to establish breastfeeding.

It was clear from the survey responses and focus groups that whilst women made decisions based on models of care and locality etc, perceptions and knowledge of the facilities available in the ACT also played a strong role in their decision making.  For example a significant factor upon which women made their decisions was the Neo-natal Intensive Care Unit and specialised care services which were available at The Centenary Hospital for Women and Children. Concerns were raised about response times should their child require higher levels of intervention or clinical care, and there were fears that mother and child would be separated should a transfer to the Territory’s tertiary hospital be required. Many women had made this choice based on the (incorrect) advice from GPs and friends that the Centenary Hospital for Women was the only hospital able to provide support with ‘problems’, and many believed/had been told that they and their baby would be separated if the baby needed to go to the NICU.
More recently WCHM conducted some small focus groups in August and September 2018 with women who had accessed ACT public maternity services in the past 12 months or who were pregnant or planning to have a baby, and explored whether women knew about the models of care and what they meant. 
Women said: 

I didn’t think about models of care. It sounds like an official term that only means something to people who work in hospitals.

I wasn’t told about options for model of care.

I didn’t understand what model of care I was using.

Difference between CaTCH and continuity programs is confusing. All the acronyms and everything.

Understanding of the models of care / finding out about the models of care
When they were asked about where they obtained information about the models of care in 2015, 71 of the 116 women who answered this question advised that they received information about the available models of care from General Practitioners, and 48 through their midwife. Most identified getting their information from friends/family (85 of the 116). 
Websites also played a role in woman accessing information (for 46 of the 116), and participants identified a number of web based sources of information they used, including Essential Baby, Riot Act, the Canberra Mums Facebook Page, ACT Health, Women’s Centre for Health Matters, What to Expect When You’re Expecting, and the individual Hospital websites.
When seeking confirmation and information from their General Practitioner many women reported that their General Practitioner was helpful and provided them with information that was up-to-date and of a high quality. However other women reported that General Practitioners as a first point of contact often did not provide the information or the links to information that could help them decide on the options. 
Women said: 
I found that my GP did not provide me with any information on what I should do next in relation to my pregnancy nor did he seem to care that it was my first pregnancy and I didn't know what to expect.

I went to the GP. He did not give any useful information.

I went to my GP and he said "congratulations, when are you due?" and that was about it. He wasn't very helpful, and didn't even mention the Birth Centre until I did.

I went to my GP who wasn't as helpful in giving me information about the birth process in Canberra but who was helpful with the health aspect of things.

GP asked where we were planning to have bub, but didn’t provide guidance really at all.

I went to the G.P. She told me to contact the hospital and to book somewhere for a 12 week ultrasound. That's all the info she gave me. She wasn't very informative, to be honest, I found out more from books I bought myself.

In our 2018 focus groups, we also explored where women found out about their options. Most women found out their information about what was available through friends and Facebook groups. 

Women said: 

Knew about the Birth Centre and CaTCH. Heard about services through friends and Facebook groups.

I was lucky I had friends who had been through the Birth Centre. Continuity was really important to me.

Public didn’t offer me much at all because I didn’t fit the criteria for this, didn’t fit the criteria for that.

GP referred me to a shared care midwifery model so I almost missed the chance to go to the Birth Centre. Found out about it at 16 weeks pregnant, but no call back from the Birth Centre until 21 weeks.

My GP just asked “private or public?”. My GP said public services are better. 

This reinforces the importance of ensuring that accurate, easy to access and up-to-date information about the different models of care is available for women and also for their GPs, friends and family, to allow pregnant women to make well informed choices about their care options. 
The models of care accessed
While some women accessed care led by obstetricians or GP shared care, women particularly highlighted midwifery-led care. 
Women said: 

I liked the GP/midwife shared care model because I felt I had the best of both worlds. I liked the continuity of care, liked that someone was following my case regularly and liked that a physician could oversee my case as well. 

Most women commented on the importance for them of building a relationship with those providing their maternal care, and the importance of that familiarity contributing to more person-centred models of care.  The women in the survey and focus groups highlighted the importance of the development of these relationships during pregnancy to ensure that the benefits were achieved during labour, birthing and post-natal experiences. 
Women reported the relationships they had with their care providers was a critical factor in how they managed and felt about their pregnancy and that midwives provided security and confidence in both the relationship and the process of birth.
Women said: 

I will definitely search out my midwife and get her next time. I don’t care if she was at John James, even if she has changed jobs I’m going to track her down. So there is definitely that loyalty. It’s a big step in your life, a huge moment, you want someone there that has your best interest at heart. 

I had great midwives through my labour and that was fine but as soon as I got back to the ward I didn’t see them again and that was it. I felt really abandoned. 

During my labour they were fabulous and I couldn’t fault them just that afterwards it would have been nice of them to follow through and check in to see how we were going. I felt stuck on the ward and that I couldn’t get out of. I was in hospital for a week because I ended up with a c-section, it wasn’t like I was there for a few days. 

We have private health and where willing to pay for private obstetrician. But we really liked the care model of a midwife and continuity of care option at Calvary birthing Centre.

In the birth centre we had our own midwife who went to my house for the first visit. My midwife provided great continuity of care.

The care from my last obstetrician and midwives especially during labour was absolutely exceptional and I wish the same for my next baby.

The knowledge experience and guided approach of my Obstetrician was inspiring. The process of relaying procedure and potential things that could happen prior made me feel in control aware but never scared.   

I absolutely loved my midwife and got along very well with her. Having the continuity of care was fantastic. I love the philosophy of the birth centre.

Women also valued birth centre care because they felt it increased the likelihood of having a natural birth (and drug-free) and gave better capacity for continuity of care.
Women said: 

I liked the GP/midwife shared care model because I felt I had the best of both worlds. I liked the continuity of care, liked that someone was following my case regularly and liked that a physician could oversee my case as well. 

The continuity of care, the excellence of care by all midwives at birth centre, the great previous birth experiences at birth centre and my passion to birth naturally, calmly and how I choose to, drug free.
Birth centre- loved the philosophy and continual care model!

I went through the Birth Centre at Canberra Hospital as I wanted their continuity of care program so that I could have the same midwife all the way through my pregnancy.

I wanted an intervention free natural birth with a good continuity of care model.  I also wanted the option of a water birth if that is how I felt on the day.

Birth suite. No epidural. More natural.

D. Management of patient birthing preferences, including, but not limited to, professional advice offered to patients, and the practices associated with birthing emergencies.

Overall women felt that better communication about why decisions were being made was critical to better outcomes, regardless of the birthing experience that women have, and that this must be linked to good practice to be employed by the maternity care professionals working with women. 

Involvement in and understanding about decision making
Current expectations of good maternity care emphasise the importance of women having a choice and being involved in the care they receive. Women in our consultations described the importance of being involved in the decision-making about their bodies and their babies and having the ability to be kept informed about what is happening to them, having an understanding about the decisions being made and being able to exercise choices and preferences in the decision-making. 
Our consultations with women revealed that trauma can be a part of the birthing experience for some women, and that for many of the women who took part in the consultations it involved some level of intervention that they were not expecting and had not been informed of or understood to be needed. Women described how decision-making was taken out of their hands and that it was usually upon reflection that they felt it could have been managed in a better way. 
Many women also told of us of the adverse impacts for them when they experienced levels of intervention that they were not expecting and had not been informed of or understood to be needed. Women expressed concerns about the lack of debriefing after the birth about the decisions that had been made, why they had been made and talking to women about what had happened to their bodies.
Women reported having an understanding that sometimes decisions needed to be made quickly, and that sometimes they didn’t have any choice, but felt that the way in which those decisions were made and conveyed could be improved through practitioners understanding the impact on the women when they were not informed about what was happening. 
Several women highlighted that even though they had experienced trauma during their birthing experience, they were also given a debriefing session with midwives within 72 hours of the birth and they relayed how that made a real difference to how they were able to reconcile the reality of what had occurred with the ‘ideal’ they had initially taken into the birthing process. 
Some women provided stories about how the trauma they experienced was handled in helpful ways and others gave examples of unhelpful support strategies.
Examples of helpful communication from women:
I remember afterwards two nurses came and sat with me and went through the notes to explain exactly what had happened to me. They explained everything to my partner and kept him calm and said that we should stay in the hospital afterwards. 

The explanation of each potential process, answering all my questions and requests. for example when baby’s heart rate dropped they clearly explained what needed to happen next how much time we had and what my options were.

The midwives and theatre staff were all fantastic, very supportive. Everything was explained very clearly to me as things changed and we had to go to theatre.

My obstetrician and the midwife kept me informed when things didn't go to plan and I appreciated the time they took to explain why. I also appreciated that they attempted the vaginal delivery first with forceps before going to the Caesarean option which I was not keen on and in the end didn't need.

The impacts on women’s preferences and choices by professionals
Some women reported feeling pressured by medical staff to go against their choices in relation to their birthing preferences. 
Women said: 

My birth plan was completely ignored and I wasn't consulted about my options.

I was pressured into an induction as I had not progressed. I argued against it and refused to do anything until my mother arrived - which was met negatively.

When complications developed and I had to see obstetricians I found them dismissive of my concerns and disinterested in my preferences for care. 

Others told us that they felt their choices were impacted upon by lack of information, or incorrect information.
Women said: 

My not checking epidural was done, not informing me or asking if they could use forcerps and not explaining how to use the gas or what the epidural would do

MACH / Midcall nurses
There were varied reports about the practice, service and attitudes of MACH nurses – many were positive and highlighted that their patience and time was critical to helping new mothers develop confidence. Other women reported they felt rushed, that their questions were not answered and that they needed more information and support from the nurses during this time. 
In the recent small focus groups with women who had accessed ACT public maternity services in the past 12 months, some who had experienced difficulties after birth, or of babies not feeding or being unsettled etc found that some MACH nurses were dismissive of their issues. 
•	Didn’t use the MACH nurses much. I wasn’t impressed with them. They were very dismissive.
•	I was having problems with my baby not gaining weight due to a poor milk supply. I had to go back to my GP to get the help I needed with my baby as I was not being listened to by the MACH nurse.
Women spoke about the Midcall appointments and the initial at home appointment with MACH nurses seeming like they were a lot of box checking and not so much concerned about the mother and her health.
•	On reflection I was doing really well for a first time mum but I still felt underprepared & overwhelmed. The care at this stage was very much focussed on the baby whereas I still felt do unwell (because of the infection I didn't know about).
MACH services were generally perceived as useful but lacked continuity – some of the women preferred to see their GP so that they had continuity and because they already had a relationship with their GP.
•	The continuity is lost with CaTCH because the midwife you saw for pregnancy and birth is not your MACH nurse.
•	MACH nurses not really listening. I just see the GP now.
•	MACH program is a good follow-up if you really use it. But there’s no continuity – it’s like using a walk-in clinic.
Other women spoke of good experiences with MACH nurses.
•	The person who came out to see us as a MACH nurse was great so I’ve made an effort to seek out the same MACH nurse at clinics by finding out what days she works.
•	MACH nurse free visits (at home) after the birth were very beneficial.

H Patient satisfaction with the services.
Our consultations showed the complex factors that may enhance or detract from women’s satisfaction with their maternity care experience.
Levels of satisfaction with ante-natal care
The women were asked how satisfied they were with the maternal care they received during their pregnancy. The women’s responses showed high levels of satisfaction in general with the care they received. The comments that accompanied the ratings about their levels of satisfaction revealed that where women there were the highest levels of satisfaction. 
One of the key messages through this feedback was that satisfaction was high when women received adequate and current information, were listened to and respected within the relationship, when questions were answered and decisions explained, and when trust was developed in the relationship. 
Where women reported feeling unsatisfied, it was largely related to a lack of continuity of care which required the women to repeat their health information, inaccurate information being provided and barriers to access such as finding it difficult to get appointments. 

When women felt unsatisfied they said: 

Lack of continuity of care. My GP was the only constant throughout my pregnancy and the hospital people I dealt with were very quick to forget about my GP needing to be kept informed.

I felt there was some overlap in the GP/OB care and it was not really made clear to me what things should be addressed to which doctor.  I was discouraged from sourcing information from the internet (which I agree is often unreliable) but then didn't always have my questions answered properly by the OB.

Some midwives were very knowledgeable but I saw a different person every time and I found their advice conflicting. It was also hard to tell when their advice was based on medical information and when they were using old wives tales.

GP was professional and efficient but did not take time to explain the details when she assessed me as high risk, which led to me feeling very anxious and upset.

Levels of satisfaction with birthing
Of the ninety-seven women who responded about their levels of satisfaction with their birthing experience, 83.5% of them were satisfied or somewhat satisfied.
Communication and information during this stage were closely linked with satisfaction and positive experiences for women. 
Where women reported feeling satisfied with their care it was attributed to the knowledge of the practitioners and care team and the empathy they demonstrated towards the woman as she experienced her first pregnancy and subsequent birth experience. Women also reported better levels of satisfaction where practitioners had taken time to explain processes and answer questions along the way. This was also linked to the listening skills of the practitioners, where if women felt heard then they reported feeling satisfied with their experiences. 
Women who were dissatisfied spoke about:
•	receiving conflicting information from different midwives, and some midwives discounting the advice provided by other professionals;
•	the difficulties they had with breastfeeding, which was often linked to the lack of continuity of carer or inconsistent advice; and
•	negative experiences due to staff who had been rude to them, their support people, or family members.
Many women who participated in our consultations reported feeling that staff members within hospital were often too busy and that they felt they received confusing and contradictory advice and information regarding breastfeeding and the care of their baby. 
Women said: 
Lack of information or contradictory information, lack of emotional support, issues not taken seriously, staff on postnatal ward occasionally rude and dismissive of concerns.

Whilst still in hospital the advice I received I had to ask for and each time the hospital staff made me feel like I was a burden. The advice I received from the staff was inconsistent and at times, completely contradicted what a different staff member had said earlier in the day.     

I found that I was told a lot of conflicting advice which was confusing and unhelpful.

Whilst still in hospital the advice I received I had to ask for and each time the hospital staff made me feel like I was a burden. The advice I received from the staff was inconsistent and at times, completely contradicted what a different  staff member had said earlier in the day.     

The midwife I had was not a very kind lady. She talked about me in front of me in an unkind way. She also didn't know my best friend was my student and said some rather rude remarks to her about me. She wasn't sympathic to the fact that I was scared and didn't know what was going on.

Another more 'senior' midwife was rude to my partner when she walked in and I was screaming in agony and he was sitting on the couch.  She told him he should get up and 'help', when I'd actually told him I didn't want him near me because there was nothing he could say or do to 'help'.

A couple of the midwives were rude about breastfeeding.  I didn't know how to feed or get him to latch but was sent home anyway.  

He had trouble latching so spent three days in the hospital trying to get him to feed. I felt pushed into breast feeding and judged for mixed feeding. 

I had a lot of trouble getting my baby to latch for breastfeeding. Some midwives were supportive and gave advice and a good 'hands off' but guiding role in feeding and also helped with guidance on how to express by hand and later using a pump. I was extremely grateful to these nurses who went above and beyond to help and even took my daughter for brief periods to let me rest.     Other nurses grabbed my baby and tried to force her to feed screaming. After a c-section with nurses trying to force a screaming baby to feed every few hours I was exhausted and very emotional.

I was shown how to feed my daughter by one midwife, who was quite brash.  Then I was continously shown by a never-ending stream of midwives (well, that's how it felt), all with a different technique and manner, and it was too much.  I got very frustrated and just wanted to stick with one person, one way.  My baby started getting distressed at one point and I wanted to stop and leave her in peace, but the midwife persisted.

I was very unwell and my son struggled with feeding.  Many different midwives gave me various conflicting advice about feeding over the course of my stay which left me feeling stressed and confused.  I also saw an obstetrician who checked my son over …………… , and this obstetrician made disparaging remarks about my ability to breastfeed him which left me angry and discouraged.

I had negative experiences with some of the midwives I had. 

Being shouted at during labour  Conflicting results / being lied to.

Rude midwife who was uncaring.

He wrote me up for endone and left. When the midwife came in I asked for my endone and she refused telling me panadol was fine and to toughen up. When one of the midwives that had looked after me came to visit me she took one look at me, looked at my folder and walked out. She came back with my endone and asked why I hadn't been given it 2 hours ago.

The next 4 days of care in hospital were mixed. Some of the midwives were amazing others were horrible and I had to fight for the pain meds I'd been written up and for anti nausea medication.

I did suffer a post partum hemorrhage and had an episiotomy so felt extremely dizzy (to the point where I couldn't walk properly) and in a lot of pain. A senior nurse guilted me into leaving by saying that "you do realise that women who have had a caesarean leave after two nights".

Levels of satisfaction with post-natal care
Women who responded to the survey provided a lot of information about their postnatal experiences and what they found positive and negative. From the written stories in the survey it is clear that this is an extremely stressful, tiring and emotional time in the transition to motherhood. There was a divide amongst the women’s stories about their experiences of postnatal care and the expectations they had about the care they would receive. 
Of the eighty-five women who responded to this question forty women described positive experiences where their expectations were met and/or exceeded. Eight women described an experience that had both positive and negative experiences and thirty-seven women described their negative experiences of postnatal care. There were a variety of reasons for the differences in experiences which included issues such as personalities of staff and their approaches clashing with the mother’s needs at the time. 
Women also highlighted issues surrounding breastfeeding and the lack of support they felt they received in this area from staff within hospital following birth and also within programs such as Midcall and MACH Nurse visits within the home. 
The issue of inconsistency in the information and the approaches of practitioners during postnatal care was raised regularly and women described feeling confused, unsure of themselves, unsupported, pressured and fearful. Whereas those who reported positive experiences of postnatal care highlighted responses such as midwives and nurses who spent time with them, and who listened, understood, made suggestions and reassured them that it takes time for bonding and attachment to occur and that learning to breastfeed isn’t easy. 

L Any related matters.
Important areas highlighted by women in our consultations but not delivered within the hospital system related to information and support for women once they had left hospital, and the importance of funding community based options, so that there are adequate and appropriate services to provide ongoing health care for mothers and their babies. These related to postnatal services such as breastfeeding support, peer support services, and depression counselling and support. And to whole of ACT information provision.
A well-resourced postnatal support system of community based options can provide long term social and health benefits as well as fiscal savings for the overall health system through complementing the shorter hospital stays post birth, and reductions in readmissions to hospital and other entry points of the health system.

Breastfeeding support
Breastfeeding was a strong theme throughout the consultation. Women talked about the social and emotional pressures on women to breastfeed and that the information they received was that breastfeeding was natural and therefore easy, and clearly the best option for babies. 
The majority of women participating in the consultation wanted to breastfeed but many were frustrated by a lack of support, information and referral, and receiving inconsistent and sometimes contradictory advice from different staff. 
Women reported that they felt an enormous amount of pressure to “get it right”. However, they also reported that whilst in hospital they received little support and information about breastfeeding. They described situations where midwives would put the baby on the breast and leave the mother to fumble through. Women said they would prefer the midwives to be able to stay and watch and advise during a whole feed to give them confidence that what they were doing was correct. 
One of the key messages that came through was that when women were unable to breastfeed they felt like failures and this had an impact on their mental health during the formative stages of their relationship with their baby. Some reported still feeling like a failure years after the event, particularly where babies had been diagnosed with failure to thrive. 
The women who experienced any kind of difficulty clearly articulated that a range of supports were required to help them to begin and continue breastfeeding. Women who had shorter hospital stays reported that this meant they were returning home without having breastfed properly or having their milk coming in. Overwhelmingly the message from women in these cases was that they wanted someone to spend time with them and help them understand more about how to breast feed successfully. Women who were unable to breastfeed talked about feelings of guilt and failure because the message was that not breastfeeding was a bad outcome for their child. 
Many women noted the emphasis that is placed on the benefits of breastfeeding during their antenatal care, but felt there was a lack of practical support provided in the postnatal period.  Women felt that breastfeeding should be described as something that took time to master and was about learning together with your child and that if it was not possible there are alternatives and that the health and wellbeing of the child was paramount. They wanted much more support following discharge in the home and also wanted to know more information about and access to community support options and access to lactation consultants. 

Women said:  

I wish I had had access to reliable and accurate lactation advice.  I wish I had been more assertive about my concerns.  I wish I had known more about what I was going through so I was able to make more informed decisions.

I was in tears as my baby was not yet feeding and I had no knowledge of how I could feed her when I got home.  I privately consulted a lactation consultant when I got home and it was through her that I received some advice on working on getting my baby to latch, pumping in the meantime and what free and public support services were available.

I had issues with feeding which I feel were caused by my caesarean and exacerbated by the different opinions I came across in the hospital. I was made to supplement with formula despite repeatedly saying that I did not want to.   

I left hospital 8 hours after my baby girl was born. I don't really like hospitals but I do wish now I stayed longer. I found the following days were a bit of a blur lack of sleep etc. but I saw 3 different midwives during my post birth. All of them had different advice and it was so confusing about who to listen too. I had issues with my supply and, by the time they had realised that, it was too late and it never really came in.

Lack of consistency and thoroughness between midwives  Lack of consistency between nurses at special care nursery  No consultation and a plan for what to do at home after special care nursery  No recommending services or people to hire for support post discharge.   No recommending support groups for parents. 

Maybe gotten more help with breastfeeding sooner? We didn't know our baby was hungry and I had supply issues.

should have accessed the lactation GP much sooner rather than waiting until I was in a real mess, ideally in the first week after I realised I had an issue (it wasn't until I went to QE2  in week 3 that I even knew those sorts of doctors existed).    I probably would have been better to not go to the MACH service as much as I did, I was so focussed on his weight that I was willing to try anything to fix the problem and I found that so many different and conflicting opinions just made things worse. 

The midcall midwife saw me at my home the day after we left hospital and, due to breastfeeding issues, saw me every day for the next two weeks which was very helpful.  Despite this breastfeeding was extremely difficult and I felt like I didn't have all the necessary information to breastfeed successfully and didn't really know how to access it. 

While there was a strong focus on breastfeeding I had a difficult time with it and felt frustrated with the lack of practical advice/help. 

Though the midcall midwives tried to help me as much as they could with breastfeeding (providing nipple shields and a breast pump) I found they pushed the issue too much. I became very emotional during this period and dreaded their visits.  It was not until I went to see my GP who suggested that I move to formula that I started to feel more confident about being a mother and caring for my child. I have not been back to the community nurses since as I found my GP to be a lot more supportive of my feeding choices. 

We were discharged without a clear feeding plan other than to try breastfeeding which had not been established. I was visited every day for 3 days a midwife then also on the 5th day as well. Each midwife was very different in their advice and level of experience.

Access to postnatal supports
Postnatal supports and information available during the postnatal period of time was particularly raised as an area of concern for women participating in the consultations. The postnatal period marks a significant point of transition in a woman’s life, and postnatal care extends from the hospital stay to the community and home. 
Women described feeling that they did not have adequate access to post-natal support, and for those with shorter hospital stays, there was a need for increased support in the home following discharge from hospital during the postnatal period. 
Many women talked about being in hospital for 24 hours or less and that they would have preferred a longer hospital stay to ensure their milk had come in, they got through the ‘baby blues’ period and had access to support 24 hours a day for the several days.  Many spoke positively about QE2, but others had not heard of it.
They also spoke about how following discharge could have been better if they had had more visits from MACH nurses. 
And supports for depression were highlighted. One in 10 mothers and 1 in 20 partners experience antenatal depression, with more than 1 in 7 mums and 1 in 10 partners experiencing postnatal depression. Perinatal anxiety is just as common.  While PANDSI has significantly increased its delivery of services over the past five years in an attempt to better meet demand and some increases in funding over the past 5 years has been given, the funding has not kept pace with the demand, or the changing needs. 
Access to information
Our consultations identified that one of the main areas for improvement highlighted by women was the area of information provision to women at all three stages of having a baby in Canberra.  A consistent message provided by the women was around legitimate sources of information particularly following the birth of their baby. With 24 hour access to information from all over the world via the internet, women reported feeling confused and not sure of who to trust in terms of information and would like access to a trusted source of information that in particular refers to local resources and services, as well as some of the more generic national information. 
Women spoke of the difficulties associated with receiving information on the range of maternity care options available in the ACT and the availability of local services, and that the information available was siloed and related to the specific services provided by the hospitals, or were at a national level so did not include the range of options for local supports in the Canberra area. 
Women said:  

I did some research online before I fell pregnant and requested a referral to the birth centre from my GP.   I found it tricky as not all information is in the one place, also hard to tell the difference with the services, especially if you could not get into your first choice. Nothing at all about options for home birthing and doulas.

I found the websites were incredibly confusing and not very intuitive and my GP at the time had no idea about birthing options.

My GP here told me nothing. It wasn't even clear that in the ACT you can go to any hospital regardless of location. I searched the hospital websites (mainly through Google) to find information on the birth centres and then called up directly because the websites weren't all that clear either on the process for applying

Women wanted consistency in the information they were able to access about the options and care choices available in the ACT. The consultations found a need to more clearly assist women to assess what local choices are available, where and when they can be accessed and which would provide appropriate independent information and referral pathways into the local non-hospital based services and non government services that provide for where the woman is at, at that moment in time. 
As a result of this, WCHM developed the Having A Baby In Canberra website which provides a centralised source of local ACT information for women (and their partners and families) and helps women to make informed decisions and choices at all stages of their pregnancy. It provides information across the continuum including planning for pregnancy, choosing maternity care, information to inform where to have a baby (including the models of care and facilities at each hospital, and advice for the postnatal period).    
The website was launched on 4th September 2017 and has attracted over 14,000 visits from 1 December 2017 to 30 November 2018. 

The website is available at http://www.havingababyincanberra.org.au/

Conclusion
This submission highlights what women in the ACT and surrounding region have told us about their experiences in relation to maternity services in the ACT, as well as the feedback to us from some of our partners who provide community based services that support women. 
WCHM would be happy to expand further on the points made in this Submission as required.