Women and 
Maternal Care in the ACT
Consultation Report

Melanie Greenhalgh
May 2016

ACKNOWLEDGEMENTS 
Thank you to the local women who took the time to participate in the research.  We recognise that the time after giving birth is a busy time of life and involves both positive and negative experiences which can be difficult to discuss. We hope that the results described in this report honour your valuable insights about your experiences and your views about responses in the ACT might be improved.
Thanks also to Charo Gallacher who was a Masters of Social Work student placement from the Australian Catholic University, Canberra. Charo worked on this project and assisted the Centre in developing the consultation framework and engaging with the women to ensure that their voices were represented and heard. 

                	

Publication/Copyright Information
ISBN 978-0-9944342-2-7
© 2016 Women’s Centre for Health Matters Inc.

Published by Women’s Centre for Health Matters Inc.
This publication is protected by copyright.  Apart from any use permitted under the Copyright Act 1968, no part may be reproduced without acknowledgement.

About Women’s Centre for Health Matters Inc.
The Women’s Centre for Health Matters Inc. (WCHM) is a community based organisation which works in the ACT and surrounding region to improve women’s health and wellbeing. WCHM believes that the environment and life circumstances which each woman experiences affects her health outcomes. WCHM focuses on areas of possible disadvantage and uses social research, community development and health promotion to provide information and skills that empower women to enhance their own health and wellbeing. WCHM undertakes social research and advocacy to influence systems’ change with the aim to improve women’s health and wellbeing outcomes. WCHM is funded by ACT Health. 
About the Author
Melanie is a Health Promotion Officer at WCHM, and has a Bachelor of Youth Work. She has always been interested in how the social determinants of health impact on the ability of people to thrive. She continues to explore this in her role at WCHM. 

Contents
Executive Summary
Recommendations
Methodology
Demographics of Respondents
Age
Area of Canberra
Hospital accessed
Women’s decision making about where to birth
Chapter 1: Pregnancy
What Women Said
Finding out about a pregnancy
Information about models of care
Where information about models of care was obtained
Accessing ante-natal care
Levels of satisfaction with ante-natal care
Key themes of Pregnancy Consultation Findings
Access to Information
Continuity of care
Perceptions of services available at hospitals
Chapter 2: Giving Birth
What Women Said
Experiences of birthing
Levels of satisfaction with birthing
Key themes of Birthing Consultation Findings
Communication and information
Decision-making
Debriefing after the event
Chapter 3: Post-natal Care
What Women Said
Experiences of post-natal care
Information Provision
Access to information and advice
Access to services
Levels of satisfaction with post-natal care
Key Themes of Post-Natal Care Consultation Findings:
Access to post-natal support and services
Breastfeeding support
Access to Post Birth Information
Discussion of key themes
Information provision
Ideal experience
Choice and involvement in decision-making
Improvements to models of support and care
Conclusion

Executive Summary

“Giving birth isn’t a condition, it’ s not a big thing, it’s not an injury, 
it’s something that you just need to be supported through” (Participant)

Each year in the ACT, over 5,500 women give birth, so maternal care is an important part of our local health services. Maternal care involves checking on the wellbeing of a woman and her baby and providing care and support - from prenatal or antenatal care during pregnancy, care during labour and birth, to postnatal care after birth. 
Providing pregnant and birthing women with good care can improve their lives and their children’s both immediately and in the long term – this is because women’s experiences during pregnancy and birth can impact on how women feel about their babies, themselves as mothers and in their other relationships.
It is true that women have been giving birth for centuries and that generally we have seen an improvement in the circumstances under which women receive care and assistance to bring their child into the world. However, each and every day a new woman comes to the moment of pregnancy, labour, birth and the lifelong role of being a mother. We must never forget that for each one of these women there will be a variety of feelings, wants, desires, experiences and hopes for this part of their life. We must also take into account the changes that occur in the systems that surround these women. These elements of the journey require evaluation and analysis to ensure that changes still give mother and child a healthy, positive and caring start to their lifelong relationship. 
Antenatal care, labour and birthing and post-natal care at any healthcare facility are intended to ensure safe outcomes for mothers and babies alike. Good patient and doctor/midwife relationships can promote patient satisfaction and trust, and it is the primary duty of the healthcare system to be aware of the patients' needs. Modern concepts and research in the field of childbirth, stress the involvement of patient choices at all times throughout the provision of their care.
Women’s experiences of pregnancy, birth and life after having a child have been long researched and there is an abundance of literature and knowledge available. However, it has been approximately 10 years since the examination of maternity services in the ACT where women’s voices and experiences were directly collected to inform the development of maternity services and policy in Canberra. 
It is for this reason that in late 2015 the Women’s Centre for Health Matters (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. 
The following report summarises the results of the consultation, and provides the feedback and narratives of 171 women who had given birth for the first time in the ACT or Queanbeyan, since August 2013, and who participated in an online survey and/or focus groups. Women were asked about their experiences of 3 areas – pregnancy, giving birth and post-natal care. The report provides an analysis of the key issues identified by the women directly which is supported through the use of quotes from the women’s voices. 
This report is comprised of several parts. The first part describes the methodology used and the demographics of the respondents in this consultation. Next are chapters on Pregnancy, Giving Birth and Postnatal Care, with each chapter outlining the major consultation findings from the survey questions and the focus groups followed by a discussion of the major themes identified. The conclusion outlines the overall key findings from the feedback from both the survey and focus group respondents. 
From the words and stories of the women in the consultation it is clear that what is best care for one woman is not for another. The consultation identifies that whilst some women appear to have positive experiences and are able to safely deliver their babies with the support available, there still appear to be areas for improvement. This was strongly the case in the area of information provision to women at all three stages of having a baby in Canberra. 
Women wanted consistency in the information they are able to access about the options and care choices available in the ACT. The analysis of the consultation found a need to more clearly assist women to assess what local choices are available, where and when they can be accessed and which provides appropriate information and referral pathways into the local government and non-government services that provide for where the woman is at, at that moment in time. 
Women also identified that continuity of care stills remains an important aspect of having a baby as does women being included in practitioner’s decision-making about their bodies and their babies. Women particularly identified concerns about the lack of debriefing after the event about the decisions that had been made, why they had been made and talking to women about what has happened to their bodies. 
Women also need accessible, acceptable and affordable services and this consultation found that overall for many women this was the case. Other women told us directly that the services they received were not accessible, acceptable or affordable and that improvement needs to be made in order to ensure women have positive pregnancy, birthing and postnatal care experiences. 
The consultation revealed that trauma is a part of the birthing experience for some women. Interestingly, the definition of trauma was varied, but for the women who took part in the consultation it involved some level of intervention that they were not expecting and had not been informed of or understood to be needed. Some women provided stories about how the trauma they experienced was handled in helpful ways and others gave examples of unhelpful support strategies. 
This consultation provides us with information to suggest that positive outcomes are possible regardless of the birthing experience women have, but that they are linked to good practice being employed by the professionals working with women. Women clearly indicated that good practice is about being kept informed about what is happening to them and being included and having an understanding about the decisions being made. 
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 women who experienced any kind of difficulty clearly articulated that a range of supports were required to help them begin and continue breastfeeding. The majority of women participating in the consultation wanted to breastfeed but felt many frustrated by a lack of support, information and referral. 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. 
Women’s experiences of choice and involvement in decision-making was highlighted as a theme across all three of the stages of pregnancy, birth and postnatal care. Women were aware of the importance of decision-making about the maternity care they received. The women’s stories conveyed how poor involvement in decision-making could have lasting impacts on the health and well-being of the women, child and her family. To enable women and their families to exercise choice, they needed to be aware a choice was available, and to have access to enough appropriate information and communication to enable them to make an informed decision. 
Postnatal support and the information available during the postnatal period of time was particularly raised as an area of concern for women participating in the consultation. The postnatal period marks a significant point of transition in a woman’s life. The period of postnatal care extends from the hospital stay to the community and home and is provided by multiple caregivers. Women highlighted that with shorter hospital stays there is a need for increased support in the home following discharge from hospital during the postnatal period. The women who participated in the consultation reported feeling that staff members within hospital and home settings were often too busy and that they felt they received confusing and contradictory advice and information regarding breastfeeding and the care of their baby. 
The consultation also reinforced the importance of General Practitioners as a key source within the community in providing information to women about pregnancy, birthing and post-natal supports and the options available to them.  They are often the first point of contact and a key player in providing ongoing care for women during pregnancy and after birth, so there is a need to ensure they are supported to provide accurate and up-to-date information to women.
WCHM hopes that listening to ACT women’s views and their different experiences of this important stage of their lives will provide an opportunity to respond to feedback on the way that maternal care is provided in the ACT. And by documenting women’s stories about what worked and what did not, we hope the report also provides an opportunity to understand what aspects of the maternal care system in the ACT the women valued.

Recommendations

1. That WCHM, in conjunction with ACT Health, develop and implement a web based information portal which provides information on birthing options, models of care and the hospitals and facilities available in the ACT and Queanbeyan along with other areas such as breastfeeding and post-natal supports available in the community. This portal would be developed in conjunction with maternal healthcare stakeholders in the ACT local community and ACT Government services, with the overall aim, to ensure that women are aware of and can access local and relevant services and support at the right time in the right place to receive the right care. 

2. That WCHM, in conjunction with Primary Health Care Network and ACT Health, develop an online tool that allows General Practitioners to create a profile of the woman and her pregnancy that assists to rate the as low, med or high risk which then matches her to information about the care facilities within the ACT and Queanbeyan that can best meet her needs. 

3. That ACT Health undertakes a review of the current post-natal home visits model of support for women following birth, to ensure that the model is based on the current needs of women and the changes to the maternity system since the model was first introduced (including the variations in their support needs dependent on the length of hospital stays).

4. That the ACT Government develop an ACT Maternity Services Framework by undertaking a systematic review which looks at what the ideal maternity services look like for women based on the evidence available locally, nationally and internationally. There is a wealth of global data available and we need to ensure that we are using this to inform and develop services that are accessible, affordable and acceptable. 

Methodology
To inform the consultation WCHM used a mixed methodology. The consultation comprised of two parts, an online survey followed by 3 focus groups with a diverse group of women who identified as women who had given birth for the first time in the ACT or Queanbeyan, since August 2013.

To attract participation in the online survey a flyer was distributed through WCHM’s networks and through other community organisations, service providers and Community Development Network (CDNET). Advertisements were placed on the WCHM website, Facebook page and the ActewAGL Community Switch, Canberra Times Fridge Door and ACT Communities Online.

As a result, 181 women responded to the survey. Of those 10 were excluded because they did not fit the consultation criteria. There was a trend from participants to skip questions in the last half of the survey. This could be due to a range of factors including length of the survey, as the survey addressed pre-natal, birthing and post-natal experiences, the fact that the women targeted all had toddlers and were probably feeling quite time poor. Whilst this consultation does not provide a representative sample the responses within the survey provides common responses and insights about the experiences of women’s maternal health care in the ACT. 

The online survey provided all participants with information about the project and an indication that by completing and submitting the form, they were consenting to their information being stored and used for the purposes of this consultation. 

The online survey was also used to directly recruit participants for the focus groups. The final question asked women to indicate if they would like to participate and if so to provide contact details. Twenty six women expressed interest in participating in the focus groups. 

In an attempt to provide access to all women interested in participating in the forums, WCHM ran three focus groups at different times across the day and week. A WCHM Health Promotion Officer facilitated the focus groups, with the assistance of a Masters of Social Work student. The focus group questions were developed to further inform the survey results as well as to explore areas or questions that WCHM wanted to understand in more depth. The focus groups were led by the women participating to ensure they were able to bring forward the topics or issues that held importance for them. 

This report is presented in three chapters which correspond to the structure of the survey and focus groups - pregnancy, giving birth and post-natal care. Each chapter details the overall findings from the women’s feedback, and is supported by direct quotes from the women in the survey and focus groups about their experiences. 

Demographics of Respondents
There were 171 submitted responses to the survey. All of the respondents identified as having given birth in the ACT or Queanbeyan NSW within the previous 2 years. The following demographic information is based on their responses. 
Age
The following table and graph shows the age groups of the respondents who answered the question about their age. 
More than 70 percent (109) of the women who responded to the survey fell into the 35–44 year old age group. The 25-34 year old group comprised of 21 women and the 45-54 year old age group had 19 respondents. The survey was not completed by anyone aged 15-24 years or 46 plus years. Twenty-two respondents did not answer this question. 

Area of Canberra 
The following table and graph shows the locations of the respondents who answered the question about which area of Canberra and surrounding NSW region they currently reside in. 
Tuggeranong (41), Belconnen (36) and Gungahlin (28) were the suburbs with the highest numbers of women responding. Inner North Canberra (14), Weston Creek (12), Woden Valley (10) and Inner South Canberra were the next areas of Canberra respondents resided in. 
Of the respondents who skipped this question seven women answered through the comments section that they were living in Queanbeyan and 5 women came from the NSW region surrounding the ACT. With these comments included 10 respondents did not answer this question. 

Hospital accessed 
The women were asked where they gave birth and their answers are represented in the table below.
 Seventy-seven (52%) of the women who responded to the survey birthed at the Centenary Hospital for Women and Children which is a public provider in the ACT. Of those seventy-seven, 4 respondents commented that they had used the Birth Centre facilities located within the Centenary Hospital for Women and Children. Thirty-eight (26%) of the women accessed the public services provided by Calvary Health Care ACT public hospital followed by seventeen (12%) respondents birthing at Calvary John James private hospital. Ten (7%) women who responded to the survey 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. Twenty-five did not answer this question. 

Women’s decision making about where to birth
Participants reported a range of reasons which influenced their choice of hospital. The factors that played a part in their decision making included cost and affordability, available facilities, the models of care, whether their Obstetrician delivered there, recommendations from peers and family, and the length of time they were able to remain in the hospital where they gave birth. 
Facilities Available
Participants referred to the facilities being provided at each hospital as an important part of their decision making about where to birth. In particular, the more recent opening of The Centenary Hospital for Women and Children rated highly because it was new and perceived to be of a higher standard and able to provide better quality of care. Participants also commented on The Centenary Hospital for Women and Children being a better choice for them because of access to tertiary interventions should they require access to the neo-natal intensive care unit or higher levels of intervention.
Women said: 

The facilities were newly opened and so I assumed of better quality.

I felt it was the safest option. If the birth didn't go well and the baby needed NICU, all these facilities are available at TCH.

We found the staff at Calvary were more positive and inclusive of same-sex couples, the atmosphere was more personal and welcoming. 

Newer facilities at the Women's and Children's hospital appealed to us as well. 

Toured the facilities at Calvary and was happy.

Facilities are also much nicer than Calvary public and TCH also is better equipped for an emergency with the baby.

It's a tertiary hospital, if something went wrong I’d rather already be where I need to be rather than be transferred from elsewhere.

The ACT Hospitals felt huge and overwhelming so we chose Queanbeyan.

Models of care 
Participants repeatedly made reference to the models of care as having a large influence in their decision making about where to birth their child. Of particular note was the midwife 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 many women. Note: Only one respondent referred to the Birth Centre program at Calvary Hospital as it officially began towards the end of the period the consultation was targeting.
Women said: 

We wanted to be a part of the Canberra Midwifery Program - which we got into. And we wanted to give birth at the most established hospital that could provide the best care in case of emergency or any unexpected outcomes.

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 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.

Low rates of intervention and I liked the shared care system better, where a single doctor gave care before and after birth as well as being the doctor present at birth.

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

Locality and proximity to home
Some participants identified that they chose to have their babies at a hospital which was considered local and close to home. This was described as convenient, easy to get to and that aspects of their care such as appointments would take less time because they would not have to travel as far. 
Women said: 

Close to home, positive experiences of friends.

Close and had a place in the birth centre.

Close to home, community feel of hospital.

Local hospital.

My husband and I are both nurses at the hospital and I thought it would be convenient to make appointments to fit in with our shifts.

It is a brand new hospital, close to work and home.

It was the closest hospital to me and it had a NICU and SCN (complicated pregnancy).

I live close to Calvary Hospital.

Close to home. Public. Free. If any complications, I would have been taken to Canberra hospital anyway. 

Cost and affordability 
Participants talked about cost and affordability being a consideration in their decision making process. Private health care was described as not an option for some women as they could not afford it. 
Women said: 

…..wanted to go public as could not afford private and did not think that it was necessary.

I wanted public hospital care (affordability).

Location close to my home and easily accessible by public transport, no/low cost.

I don't have private health insurance, so private was never an option for me.

Could not afford private health care.

…..we couldn’t afford to go private

…..we were thinking of going private because my blood pressure and my age. At that point I rang them and they sent out a schedule of fees and I nearly died, fell off my chair, it was all so expensive
Many participants talked about how they preferred to have obstetrician led care. This was contextualised with a variety of factors generally linked to risk factors and feelings of safety. 
There was also a group of women who reported that they did not choose where to birth as their choice related to booking into the facility where their Obstetrician worked.
Women said: 

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.

Both my mother and sister had traumatic labours and I wanted to have someone - an obstetrician to make the call to intervene before I was labouring for 24hrs. Peace of mind.

High risk pregnancy type 1 diabetic and wanted my own doctor.

[I chose an obstetrician because] Private health insurance, high risk pregnancy, mature age mum, wanting access to close attention and support post birth as I have an arm injury.

Family and peer recommendations
Participants also reported that family, friends and peers had an influence in their decision to birth at a particular hospital. They generally reported that the people they took advice from had had good experiences at a facility and therefore this was influential in their decision-making. 
Women said: 

I wanted to give birth in the Birth Centre at The Canberra Hospital because I had friends birth there and they said the experience was really good.

Close to home, family and friends had birthed there with good experiences.

Great feedback from other mums. 

Friends had been there with good experiences.

I have had many friends give birth at this hospital and they had a wonderful experience. Plus it was close to home.

I went away and spoke to my very good friend and she told me that another friend of ours has used a particular obstetrician, because at that point we were thinking of going private because my blood pressure and my age.

Length of hospital stay post delivery
Participants reported that the allowable length of stay following the delivery of their child was also an important part of their decision making process. On reflection many women talked about wanting to be allowed to stay in hospital for more than 24 hours. Participants relayed that this was because they wanted to establish breastfeeding and have 24/7 support on hand to begin their journey with their child.
Women said:

The standard stay at John James is 5-6 days after having a baby. 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.

I'd heard about its reputation plus it was my local hospital. Was happy to hear that you weren't asked to leave within 24 hours like other hospitals in the region.

At least you’ve got someone helping you. I think I would stay in hospital longer.

That’s one of the reasons why I chose a private hospital, because I knew that I could stay.
In hindsight I would have asked to be transferred to whatever it is post-delivery suite and stayed. 
I did feel pressured to go home because I had been in there 4 days and I knew they needed beds, there was lots of babies due at the same time so. But I do not think women should be discharged before they have had the baby blues. 

Queanbeyan hospital……..run a bit of a different program where you can stay a little bit longer from what I believe and in retrospect that would have probably been a really good option for us too. Being a first time mum having that support around for just a little bit longer. 

Since I have heard about Queanbeyan hospital and that you stay a bit longer and since I have been through what I have been through it would have been really helpful for us. 

Chapter 1: Pregnancy
The analysis presented in this section is based on the information provided in the surveys and subsequently collected from the focus groups.
What Women Said
Finding out about a pregnancy
Participants talked about seeking confirmation and information from their General Practitioner. There was a mixed response from this area of the consultation as some 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 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 available that met their preferences. 
Women’s Helpful Experiences:

We figured I was around 6-7 weeks and booked in with our nearest GP. She wasn't very helpful and as this was our first pregnancy we knew nothing so it was very scary. She gave us a referral for 12 week blood tests and scan and said that would confirm the pregnancy and would also confirm our chances of having a Down Syndrome baby and then we could go back and discuss if we wanted to keep the baby or not. This horrified us and we knew no matter what we wanted our baby and it just made us more scared of the situation. We then changed GP to Queanbeyan and found someone lovely who took the time to explain everything and give us a lot of information and we left feeling much happier!

Because of a medical condition, my GP was closely monitoring my health at the time I was trying to conceive.  She gave me a print out of all the OBs in Canberra and I googled these and found they were all generally well regarded so booked with the one my GP recommended most highly.  I met with the OB in her offices after 12 weeks had elapsed.  Up until this point my GP was managing my health.

My GP explained the whole process.

Women’s Unhelpful Experiences:

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. 

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. I felt more informed once I spoke to the hospital too, they were great. So I didn't opt for shared care. However no-one could explain the benefits of their catch program and the like, the website is also terrible on this topic.

My mum ended up going to the hospital and asking for me as two different doctors failed to give me information.

Information about models of care
Women were asked what information they received about models of care, and were able to choose more than one response in this question. 

With the exception of 8 women who received no information from their health provider, 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. This is thought to be largely contributed to by the fact that most women in the survey were interested in and went on to birth in a public hospital. What these figures do indicate is the strong role that GPs hold within our community. As a front line worker and one of the easier entry points into the health system, there is an important relationship to foster here that will of course go well beyond the care of the women during her pregnancy. GPs can play a key part in providing women with accurate and up-to-date information that allows women to make informed choices and have access to direct supports within their local community. 
Where information about models of care was obtained
When they were asked about where they obtained information about the models of care women confirmed the role of General Practitioners as a key source within the community in providing information to women about the options available to them. 

Seventy-one of the one hundred and sixteen women who answered this question reported that they received information about the models of care that were available from General Practitioners. This was closely followed by information from friends/family. This reinforces the importance of ensuring that accurate, easy to access and up-to-date information is available for GPs but also for friends and family, to allow pregnant women to make well informed choices. Websites also played a significant role in woman accessing information, and participants identified a number of web based sources of information they used:
•	Essential Baby
•	Riot Act
•	Canberra Mums Facebook Page 
•	ACT Health
•	Women’s Centre for Health Matters 
•	What to Expect When You’re Expecting
•	Individual Hospital Websites
•	Baby Centre
This reinforces the importance of ensuring that available information is of the best possible quality, local / place based, from trusted sources and in an accessible format in order to allow women to make informed decisions about their ongoing care. 
Accessing ante-natal care
The women were asked about who provided them with maternal care during their pregnancy, and participants were able to choose more than one response. 

The majority of the one hundred and twenty women who answered this question (111) received maternal care from a midwife during their pregnancy. Seventy women advised that General Practitioners provided the care, followed by thirty-eight women who reported receiving care from Obstetricians, and six women receiving care from either a doula or from a nurse.
The response gave an understanding of who the women saw as part of their ante-natal care, and also reinforced the importance of the General Practitioner’s role in the care of pregnant women. General Practitioners are a key provider who can provide accurate and up-to-date information to women as they move through the transition of this life stage. They are often the first point of contact and are more accessible within the community setting to provide ongoing care for women during pregnancy because they are situated in the community and women can get an appointment fairly easily. They are more accessible than some of the outpatient clinics associated with pregnancy services in the ACT, which leaves outpatient pregnancy care for women with higher needs.
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, and gave an understanding of who the women saw as being involved in their ante-natal care. 
The comments that accompanied this rating scale about levels of satisfaction revealed that where women received adequate and current information and were listened to and respected within the relationship there were the highest levels of satisfaction. 

	Satisfied/Somewhat satisfied	Unsatisfied/Somewhat unsatisfied	Number of responses	
Midwife	92.8%	7.2%	111	
GP	75.26%	24.74%	97	
Obstetrician	80.95%	19.05%	42	
Nurse	93.75%	6.25%	16	
Other	57.14%	42.86%	7	
Doula	83.34%	16.66%	6	

‘Other’ practitioners were described as an endocrinologist, genetics counsellor, radiologists, the foetal medicine unit, physiotherapist and the calm birth course. In most cases these ‘other’ practitioners were utilised because of complications or increased risk factors – which was described as an uncertain and frightening time.  One of the key messages through this feedback was that satisfaction was high when questions were answered, 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 by the practitioner and barriers to access such as finding it difficult to get appointments. 

When women felt unsatisfied they said: 

Also I had a quick birth which at the time seemed ok but I went on to have long post-natal complications due to tearing, internal damage etc. I am 16 months post-partum and still have issues. I wonder if there could have been a little more guidance during the birth to avoid these issues.
I had some further health issues during my pregnancy related to lupus. I found that as a public patient at Calvary, while the care I received was satisfactory, every visit I had to explain my health situation to a new doctor. They would often repeat tests or give me totally different advice. Continuity of care would have been wonderful given the concerns I had with medication I was on for the Lupus and my baby’s health.

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 felt that there was an oversupply of OB appointments at which little was achieved other than the ultrasound to check the baby was ok.  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.

My GP was great but very popular so it was really hard to make appointments to see him. 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.

My GP did not know very much about pregnancy- only what he knew from his wife being pregnant!

I wasn't impressed with my GP at the time and her level of interest. Also could never get appointments to see her. 

The GP I saw was not helpful at all. I went on instinct to a specialist appointment she tried to cancel only to find out I actually did have gestational hypothyroidism. The specialist was great but very expensive for a short visit and the public health system was too overwhelmed to fit in appointments for the endocrinologist so I had to go private.

GP giving inaccurate medical advice. Told me not to have whooping cough vax or eat peanut butter while pregnant. I changed doctors. Midwives were excellent. Knew what they were doing and reassured me through out. Answered questions really well.

Midwife was good throughout pregnancy but did not act quickly enough on birth complications which meant I went through more than I needed to.

The two midwives I had were lovely and caring and went out of their way (not discharging us from home visits for 3 weeks) due to feeding issues. However they were not trained to pick up my sons tongue and upper lip tie, which after we went to Sydney due to no answers here were told his tongue was tied 70%. 

Midwives kept changing. No one picked up my extreme anxiety.

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. 
When women were satisfied they said: 

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.

No question too stupid.  Compassion when I had antenatal depression (GP and PANDSI helpline)
I believe for both my births I chose models of care where the support of the mother was seen as really important (group care through UC and Birth Centre). The midwives were really good at following up if I had a health issues and ensuring I was monitored where necessary. They asked and listened to my wants and needs.

Trust, good rapport, professionalism, experience, confidence, competence, flexibility.

Felt that all questions, concerns etc were given appropriate attention and response.  Never felt rushed or brushed off.  They understood that as a first time mum-to-be, it was a whole new world to me.

Their care factor about me. The time they spent with me. How they interacted with me. They listened to me.

Their knowledge and the level of information they provided, the empathy they showed, their professionalism, and the respectful way they treated me.

I felt I was very well looked after. All my questions were answered and someone was always there to call of I had any concerns.

The birth centre was amazing. Our midwife was incredible. We were so well educated and prepared for a variety of outcomes going into the birth. We're still in touch with the other members of our antenatal classes. That is an incredible program at TCH and we plan to give birth through the birth centre again.

My GP was amazing. As always. She’s such a beautiful person and so caring. And always made contact with the others, I had my own midwife from Winnunga that came with me to all my appointments and we did a check-up twice a week on myself and the baby because I was high risk. I had a few different obstetricians some were amazing some not so much.

I received well informed, personalised, thoughtful care & providers listened to my needs and gave appropriate advice & provided choices for me. 

Level of expertise, willingness to explain the complications of my pregnancy (metal scans showed some irregularities), compassion around the stress, worry, questions and grief about these complications.

Regular appointments with the same midwife, or midwives that worked together, ensured that everyone seemed to "know" me and my pregnancy.

Ease of making appointments, attentiveness/responsiveness of providers, and access to courses relating to labour, pain relief etc.

The midwives I saw knew their stuff and were able to answer my questions and provide me with all the info I needed.  I never had to wait for my appointment with the midwife. My GP always runs at least 1hour behind which is annoying.  My GP rushed me through and stressed me she couldn't tell which was the baby was lying (midwife could tell on first feel). I saw an OB at the hospital as I was overdue and she was so professional and helpful giving me lots of info as to when I was at and what would happen from there.

How well they listened, how accessible they were, how connected I felt to them as a care giver.

Key themes of Pregnancy Consultation Findings
Access to Information 
Women discussed their difficulty accessing information about the options available to them in regards to where to birth within the ACT and the models of care offered by each provider within the ACT. They recommended an ACT specific portal of information that allowed them to make informed decisions and choices. 
Many women reported missing out on the Birth Centre because no one had told them how hard it was to get into. Others described wishing they had known about the Queanbeyan hospital model of care and requesting that this information was available to ACT women. 
Other examples about lack of information included the role of the GP. Women felt that their GP should be able to provide them with information about birthing options in Canberra. What they reported was either GP referral to obstetrician led care or a GP simply asking women what they wanted – but many of the women told us they had no idea what they wanted at that time, and without appropriate information it was hard to make a choice. 
Women said:

I think I got some information from the GP at that very first appointment – she was very strangely reluctant to recommend one over the other – they wanted me to go off and do my research and I understood that and appreciated that she was giving me the choice but I found it really hard to find the information. 

Went to regular GP who gave us some info. I then researched a lot on the net and spoke to my sister in law who is a midwife (not worked in ACT system). I found it quiet hard to find info and work out what I needed to do next. Some straight forward simple info about birthing options in ACT would be fantastic. With all the program's/options available (eg CATCH, Calvary Birth Centre, Calvary) it is very confusing for first time parents.

I think having the online resource with all the different models of care was there, because that was what confused me, was the difference, I wanted to look at the difference between public and private, but for me there was a bit of a gap there about what was actually available to me, even in speaking to the GP they gave me the Having a baby in Canberra brochure from you guys which I knew that was out of date because I was on the board, so even GPs are not even aware that the information is out of date.

When you go online, I found that the information from the hospitals is a bit lacking as well. I just found that everything on line is really basic, I couldn’t get that detailed information that I wanted. Even when I rang the hospital, they just wanted to know if you were in labour and if you’re not, then leave us alone as we’re really busy.

I went looking on the Canberra Hospital website and trawled through that and tried to find some information, but what it doesn’t tell you is that you pretty much have to book in their as soon as you have had sex.

I found it really confusing. I was actually living in Wagga and trying to Google what hospitals existed in the ACT and what each hospital offered and what that actually meant. I found it incredibly confusing and I still don’t understand what TCH are offering at all. I just don’t get it. Other than there is a birth centre. I would have found it useful if there was a central point that had information that explained that stuff. Something that you can look at and make your decisions. 

But it was very hard to just even find out information.

(I needed) something central that just lays out the difference between the services. 

Continuity of care 
Traditionally continuity of care has always been a high priority for women during their ante-natal care and can have a significant influence on their birthing and subsequent post-natal experiences. Whilst some women accessed continuity of care led by obstetricians or general practitioners, women particularly highlighted the need for midwife led continuity of care. Women talked about the trust and honesty they built with their midwife during their care as being an important part of their experience. Most midwife led care involves where possible one or two midwives who are involved in the care of the woman throughout the pregnancy. Women reported feeling confident about the care they received from midwives and valued the knowledge they had. This is reiterated by the literature which shows that that women who have the same midwife/practitioner caring for them during pregnancy, labour, birth and post birth have the opportunity to build a trusting relationship which increases their confidence . 
Midwifery continuity of care has been widely studied. A review of midwifery continuity of care models in the Cochrane Library included 13 trials involving over 16,000 women from around the world including trials from Australia. Women who had continuity of midwifery care were less likely to need epidurals or to use other drugs for pain relief in labour or have an instrumental birth. Women in the midwifery care groups were also more likely to have a normal birth, more likely to feel in control during labour and birth, and commenced breastfeeding earlier than women who had other 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 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.

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.

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.

Perceptions of services available at hospitals
The insights provided by the women about their choices of where to receive care and birth provided a unique local picture. 
The Centenary Hospital for Women and Children was opened in stages during 2012 – 2014. It is a purpose-built facility located on the Canberra Hospital campus on Canberra's Southside that co-locates ACT Health services including paediatrics, maternity services, the neonatal intensive care unit, gynaecology and foetal medicine, the birth centre and specialised outpatient services. It is important to note that The Centenary Hospital for Women and Children is the only tertiary hospital in the ACT and surrounding region. 
It was clear from the survey responses and focus groups that whilst women made decisions based on values, models of care and locality, perceptions and knowledge of facilities available in the ACT also played a strong role in their decision making. 
Women reported that the newer facilities appealed because it was perceived to be a nicer environment, which had access to state of the art equipment and services. The perception of Calvary was that it was dark with lots of commotion going on. (It is our belief that during this period of time Calvary was undergoing some renovations and this may have had an impact on the perceptions of women.) 
The other significant factor upon which women based their decisions was the Neo-natal Intensive Care Unit and specialised care services 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. 
Interestingly, what the evidence tells us is that where women are placed into higher levels of care, for instance admitted to a tertiary hospital, they are more likely to have higher levels of intervention. This suggests that what is best care for one woman is not for another. This idea steers us toward the need for women to understand that right time, right place leads to right care. We need to make sure that we are not putting women who do not need high levels of intervention into tertiary levels of care and therefore at risk of unnecessary intervention and higher levels of morbidity. 
Part of addressing these concerns for women in the ACT is to also ensure that they understand that they will not be separated from their baby should transfer to another hospital be required. 
Women said: 

…..because if anything does go wrong Woden is where you end up and that for me was like why not be at that point at the beginning so I know that I don’t have to go through a separation and all that kind of stuff. You know knowing that he is only upstairs or downstairs or whatever it is instead of another hospital. 

Newer facilities, my mum was a midwife there in the 90's and I liked that should something go wrong I was in the best place...

It's a tertiary hospital, if something went wrong I’d rather already be where I need to be rather than be transferred from elsewhere.

Newer facilities at the Women's and Children's hospital appealed to us as well.

Facilities are also much nicer than Calvary public and TCH also is better equipped for an emergency with the baby.

Upgraded facilities.

I did a tour of Calvary and they were doing maintenance and there were mums in there and you could hear babies crying and you could hear the maintenance the hammers, drills and chiselling and I was like this is not what I want and where as though Woden was very quiet and peaceful – you didn’t even hear a baby screaming unless you know they happened to open a door as they were going past. It just felt like a nicer environment in Woden than it did in Calvary. 
I had never been to either of the places before but Canberra Hospital was just miles better than Calvary, it looked really dark and there was lots of commotion going on and heaps of people on the tour, whereas when we did the tour at Canberra Hospital it was very calm and peaceful. 
I wouldn’t go to Calvary because at least with TCH I know that the response times they can offer if something as to wrong and that involves a whole team of people paediatricians in the suite with you wouldn’t get that over at Calvary hospital, even the inconvenience of you being left behind while your baby is transported. That’s one thing but then there is also that clinical aspect too that there are potentially adverse outcomes associated with you know having to sort of move baby. 

Chapter 2: Giving Birth
The analysis presented in this section is based on the information provided in the surveys and subsequently collected from the focus groups. 
What Women Said
Experiences of birthing
Women who responded to the survey spent some time on relaying their birth experiences and what they found to be positive and negative about their experiences. There is no doubt that the majority of women found their birthing experience a positive experience. Of the ninety-five women who responded within the survey, forty-six women described births and labours that involved intervention such as forceps, vacuum or caesarean section. For some of these women their description of not having a natural vaginal drug free birth, was told as a failure on their behalf. 
However, twenty-one of that forty-six described their experiences of birthing and labour as traumatic. There were a variety of reasons for this including a lack of information, poor communication and (in some stories) moments where women’s expectations did not match their lived experiences. With this is mind it is important to note that these women also spoke about the information that they received about the ‘ideal experience’ and the difference in what they actually experienced and the stress this caused. 
The information most women received related to healthy women with low risks moving through pregnancy with no complications, giving birth vaginally and then successfully breastfeeding and transitioning into motherhood without incident. Whilst this was certainly the case for some of the women who participated, for others when the information they received about the ideal experience did not match their pregnancy experience because they experienced health issues and complications, they felt distressed and under pressure from the outset. 
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. These figures are encouraging and provide us with lots of information about what is working in the birthing process for women in the ACT and surrounding region. 16.5% were unsatisfied or somewhat unsatisfied. 
As with any consultation the reasons as to why women ranked their responses this way is individual and diverse – there were however some common identifiers that can provide us with information about how to improve this area of care into the future. Women raised concerns about how communication was managed and information given and the negative and positive impacts this could have on women’s experiences. The impact of decisions being made around women but not including them in the centre of decision-making was also highlighted, as was the importance of debriefing after the event and the impact from trauma related to intervention. The women described some of the long term impacts that unaddressed trauma could have on women’s experiences of mothering and their relationships.
Key themes of Birthing Consultation Findings 
Communication and information
On reflection following the birthing experience women reported that communication and information during birthing and labour was an important part of the process and journey for them. They also described the need for more information provision about birthing during the antenatal care of their pregnancy – women wrote and spoke about the need to be informed about the spectrum of outcomes that could occur during the birth process. They spoke about overall being presented with the ideal birth as a vaginal birth. For some of them, when their experiences veered from this and resulted in a different birthing experience with higher levels of intervention they reported there were psychological impacts that affected how they began motherhood and the relationship with their child. 
An example of a woman’s information and communication experience prior to birth:

I think back when I did those first time parent classes at the Canberra Hospital, it is sort of framed in a particular way. They don’t dwell on when things might go wrong, but I think worse than that is they show these videos of where people and I am not having a go at anyone because, natural birth, water birth etc is all well and good, but it did seem like they were pushing a particular agenda. So if you didn’t sort of have a particular understanding of just how labour and birth can happen beyond that particular perfect image that they were pushing, you would assume that that is all and that is exactly how it is going to happen. But the videos they had a particular agenda. No drugs, this is what is best and it didn’t kind of explore different kinds of birth. I would have loved to have seen a forceps birth because that is what happened to me in the end. It would have been good to explore those kinds of scenarios in a little bit more depth just to make it a little bit more realistic. 

An example of a woman’s information and communication experience during labour:

I guess I assumed (incorrectly?) that there would be more help from them in terms of "maybe try this breathing technique" or "how about we try and help you onto the medicine ball" or "would you like to try being in the bath for a while?". Perhaps if I had asked for these things they would have assisted, but in my drug-addled state it didn't occur to me to ask for things, and no-one offered me anything or really tried to explain to me what the limitations on me were once I had the monitoring equipment on

Communication also featured as a theme within the data particularly in the area of birthing and labour. Women wrote about how they valued the practitioners (be it midwifery staff or obstetricians) communicating and keeping them informed during the process. Women talked about how this helped to allay the fear they were feeling. Many felt that communication enhanced the level of trust and feelings of safety within the relationship and care they were receiving. 
Communication and information during this stage were closely linked and where there was a positive experience in this area this seemed to enhance the experiences of women, their level of confidence in the processes and trust in relationships with staff. 
In this section communication and information have been broken down into examples of helpful and unhelpful actions and strategies. The women provided clear and concise advice on how to achieve helpful and therefore positive impacts on their experiences. 
Examples of helpful communication from women:

My midwife, if she wanted me to move she would say I want you to move because of this, you know not just, can you move.

My experience was really positive from start to finish, it was really awful and traumatic birth, but everyone was so good to us from the start to finish. They were so good at keeping us informed about what was happening particularly during the period where we were going to theatre and I felt very out of control and didn’t know what was happening to me. 

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.

Good care with open communication all the way through.

My midwife was excellent and fully talked me through everything that was happening prior to the actual episiotomy.

During the labour I felt like it was all a bit out of my control so it was good to have helpful, competent people around me to assist when needed. 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.

I thought the obstetrician, anaesthetist, neonatologist, support midwives and student midwives were excellent in their care, understanding, listening skills, communication skills, friendliness and most importantly, their medical skills.

Examples of Unhelpful Communication from Women:

She didn’t really tell me what she wanted to achieve if she, I guess because she wasn’t my midwife we didn’t have a rapport. I didn’t trust her like I trusted my midwife that I had. I trusted my midwife to get me through birth and this lady didn’t listen to me, you know I’m having this baby, I’ve transitioned and she didn’t listen. She said to me you’re only 8cm so don’t push and I’m going “I’m feeling her head coming down and I can’t not push, it’s just coming.”

I expected more interaction from the midwives I did not expect the anaesthetist to make jokes about my pain or not believe me the epi was not working

Being shouted at during labour 

I actually had an emergency caesarean and I had no idea what was going to happen to me. I had no idea I was going to be by myself and that my husband was going to be in another room, my baby was going to be taken away from me and I wasn’t going to be kept up to date with what was happening. I didn’t hear him breathe, I didn’t hear him scream, I just didn’t hear anything and then I had an anaesthetist nurse come up to me and say that bub is going up to NICU and I said “is he?” She was shocked and asked “Has no one told you anything?” I told her no and she went and ripped into the midwife for not telling me. So I actually had no idea that my bub was being taken away and I knew nothing – nothing! They do not want to dwell on the negative but unfortunately but a lot of women have a not so perfect birth. 

There was also a lot of mixed messages between midwives, where things I'd been told at the information sessions were expressly contradicted by the midwife who ended up looking after me on the day (eg. the effects of pethidine on the baby after birth, etc.)

I think i would have been more satisfied if I didn’t have so many differing opinions. it was like yep taking you for a C-section then another one would come in and be like nope we are putting you back on the drip to induce you etc it stressed me out.

I was not pleased with my particular midwife. She sat in the corner for the majority of my labour without looking or speaking to me, did not update me during the labour on my progress and made a major error when she missed the positioning of my baby.

Examples of helpful information from women:

Staff were very friendly and supportive of my choices. As soon as I arrived I was made aware of my pain relief options if I needed them.

I think in something as intimate, life-changing, frightening and unknown as child-birth, it makes such a difference having people helping you that you know and trust and that are consistent in giving you information. 

Midwives were amazing, patient and always there for me. I was given the opportunity to discuss my options when things were not going according to plan. Obstetrician made point of checking up on me and explaining things clearly.

I was clearly explained all options at all points

Examples of unhelpful information from women said:

Being given misinformation about pain relief: I was told morphine would not affect my child at all, I told the midwife that the information from the hospital said that it could stay in my babies system for 48 hours, I was reassured this was incorrect. Later after my child was born an obstetrician said he definitely had been affected by morphine 2 days after the birth. Morphine was blamed for his failure to successfully breastfeed. 

I was given conflicting information about breastfeeding, and discharged 4 days after birth but before feeding had been established. My son lost lots of weight but wasn't weighed on discharge. It wasn't until, by chance, a fantastic midwife visited me 2 days later we got the help we needed.
Decision-making 
Decision-making was highlighted as a separate issue to that of communication and information and, whilst they are interlinked and dependent on one another for a positive outcome, it was important to separate them out as the women’s feedback clearly highlighted decision making as an area of concern. 
When women spoke about birthing and labour there was a mix of empowerment and vulnerability but many of the women reported a reliance on others to assist and help them understand the process and how to bring their baby safely into the world. One area of concern that came through repeatedly from the women was how decision-making was taken out of their hands and, upon reflection; they felt it could have been managed in a better way. 
Some women reported feeling distressed and upset because they were told of a decision that had been made about them in another room and did not include their input. Where this was relayed by women in the survey it was followed up with comments that along the way they wanted and felt entitled to know about the ‘why’ in decisions that were being made about them. 
Whilst this is not in any way a new issue experienced by women, it is important to continue to raise women’s concerns about decision making processes involved in their care. 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. They felt that better communication about why decisions were being made was critical to better outcomes. 
Women said: 

The midwife I ended up with, kept coming in and trying to check the baby’s heart rate, I don’t really know whether she said that, but she didn’t really make it clear to me what she was trying to achieve.

It was obvious when he was making the decisions about the birth that he hadn’t read my notes I was in there all day and they had scanned him and said that he was fine and I was waiting thinking the obstetrician was coming into to see me and I thought I was going home and would say come back in a couple of days, they came in and said we want to induce you tonight – it was just such a shock to me that I didn’t think to ask and my brain just shut down and I didn’t think to say why? You know like why am I being induced tonight and that was pretty much it. The obstetrician pretty much walked in and said we are going to induce you tonight because there is a risk he will become distressed and then walked out. I just burst into tears 

You know even if the outcome was the same I am happy with that but why did you decide to do that. 

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

My choices and preferences were supported where possible and I was able to use various options to help my birth (bath, shower, gas).
Responsiveness during labour and delivery, quick decisions and response when my baby was in distress. Responsiveness to questions

Thorough care. All concerns addressed. All decisions were my own before they intervened eg induction, episiotomy. They knew I did not want forceps and did not push the issue.

The respect and options given to me by the staff (to avoid intervention and follow my birth plan). The use of non-invasive monitoring methods.

During the caesarean I was not informed of anything in regards to my baby. Due to respiratory distress he had to go to the NICU and I only knew about that because I overheard the nurse talking about it to my husband. I waited 6 hours to meet my baby after he was born.

I was very satisfied with the way the midwives who attended my birth took my preferences into account and respected my bodily autonomy.

Felt very supported during labour, midwife was not intrusive, listened to what I wanted, advocated on my behalf when required.

I was unsatisfied by the way the supervising obstetrician didn't take my preferences into account when planning the induction, despite my preferences not posing any risk to the health of me or the baby.

Options given to me along the way

…… not informing me or asking if they could use forceps 
Debriefing after the event
The final area of interest that came from the stories women told and what they rated as important during their birthing and labouring experiences was debriefing after the event. This area was felt to be important because women want to know what has happened to their bodies and their baby during the birthing. Several women highlighted that even though they had experienced trauma during their birthing experience, they were also given a debriefing session with midwives or doctors in the days following 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. 
For those who did not get the information they were looking for, they reported very different outcomes and felt a lack of debriefing was a contributing factor to how they felt about themselves and the relationship with their baby as they embarked on the journey of motherhood. 

Women said: 

I remember afterwards two nurses came and sat with me and went through the notes to explain exactly what had happened to me.

When it was all over they went through my notes with me. 

I requested my notes and went and saw the obstetrician who delivered my baby and he, unfortunately because there was a particular incident in the actual theatre, so I went back and I wanted to discuss that with him and by the time it got to that point he just said nothing. He stopped saying anything. I was particularly upset and he just wouldn’t say anything. He didn’t even say can I get you some assistance because you obviously need to talk to someone it wasn’t until I took my notes and went to see a private obstetrician that I got a proper comprehensive debrief and a diagnosis of PTSD. 

I want to get my notes because I want to know why they came to that decision of inducing me and I really do wish I had asked why.

I was also dissatisfied with the lack of information following the birth about what happened to me. When I asked why I became obstructed and whether there was now a higher likelihood of me having a subsequent obstructed pregnancy I got mixed messages, non-responses, and evasive non-committal answers. I don't really mind if medical science doesn't have the answers, I just feel strange not knowing whether I could have done something differently (or should in a subsequent pregnancy).

We spoke a day after the birth and she did say that they should have explained a few things that were happening once the Bub was out.

The best thing was having a midwife show me my file notes and explain exactly what had happened during the birth, which helped me enormously in coming to terms with it.

After birth he and the midwife came up onto the ward and said they hadn't understood how serious my phobia was and that i made the right decision to have a C-section. It was nice to have the validation after the battle to get the decision I wanted.

My midwife and another midwife who assisted during the long labour visited us in the hospital room to talk and debrief on the long traumatic birth – it helped me a lot.

Chapter 3: Post-natal Care
The information presented in this section is based on the information provided in the surveys and subsequently collected from the focus groups. 
What Women Said
Experiences of 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 forty0 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. Once again there were a variety of reasons for the differences in experiences which included issues such as staff shortages, 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. 
Information Provision
In this section of the survey women were asked about the information they received postnatally about topics such as contraception, sexual health, postnatal depression, relationships, mental health and wellbeing. Some strong themes emerged from the survey responses to this question. Many women reported that they received a lot of information – not all of it useful, some of it commercial in nature and many felt that it was overwhelming and difficult to sort through. Others felt that the information they had received was of high quality and whilst they reported that they may have not taken it all in initially they had a good sense of where they could go for help or further information if required. 
In the area of contraception, it was clear that women in general were not receiving their information until the six-week check-up, and some felt that this too late and left a window of risk. A small group indicated that they were spoken to about contraception prior to leaving hospital based care. Sexual health conversations appeared to be limited to discussion about wound care and some general information about the timing in regards to having sex again. 
In the area of information about postnatal depression and mental health and wellbeing, there was a clear indication from most women who responded that they were asked relevant questions at several points about postnatal depression and that this was appropriate. However, a small group of women felt harassed and that they were constantly being put through checklists about postnatal depression when it was ‘obvious’ to them that they were not at risk. 
A few women wrote about how they had received some information on the impact parenting might have on their relationships, but that this was a largely undiscussed area of information. 
The overarching message from many of the women was that a lot of the information that would become relevant postnatally could be delivered prior to delivery of their baby, and in particular the key services within the ACT that could provide referrals and advice about issues that women may have following the birth of their child. The women also commented that most of the information was geared towards the needs of the baby and not about themselves. 
Women followed up these comments by acknowledging the importance of other new mothers in supporting each other through the transition into motherhood. This was particularly discussed in light of services such as the new mother’s groups, playgroups and female friends and family supporting new mothers. These were described as opportunities to get together with other women who had some experience and could provide information and advice on how to get through the early days of parenting and beyond. 
Access to information and advice
As women moved through the post-natal support period, the table below demonstrates that they come into contact with a variety of practitioners who provide information, care and advice along the way. 

Most women identified midwives in the hospital (67%) and community setting (68%) as the practitioners who provided the most the post-natal care information for mother and baby. This was closely followed by nurses working specifically in the maternity services area either in the hospital setting (15%), home visits (37%) or baby health clinics (45%). General Practitioners (42%), family members (37%) and friends (35%) were also highly relied upon and this could also be linked to their level of contact and accessibility in the day to day life of new mothers. 

Access to services 
When asked if there were services that women wanted to access during their post-natal period but were unable to, sixty-eight women responded. Of these women forty-six said that there were no services they were unable to access. The remaining twenty two highlighted several services that they would have found helpful but did not know about or were not able to access. 
These services included Maternal and Child Health Nurses (8), lactation consultants (7), mental health services (2), trauma support groups (2), and mothers group, specialist and physiotherapist (once each).
Women reported that the reasons they had been unable to access these services included their geographical location to the services, that the service did not exist, the wait times, simply not knowing at that time that such a service existed and the financial costs associated with some services. 
Overall, it appeared that access to services was possible for most of the participants who answered this question – however it is important to note that communication and information in the area of postnatal services is an important element of responding to women’s needs during this period. 
Levels of satisfaction with post-natal care
Of the eighty-seven women who responded when asked about their levels of satisfaction with their postnatal care experience, 80.5% or seventy women were satisfied or somewhat satisfied, and 19.5% (or seventeen women) were unsatisfied or somewhat unsatisfied. 

The reasons as to why individual women ranked their responses this way were defined by a number of issues and concerns. The women who were satisfied and somewhat satisfied identified aspects of their care such as being listened too, staff taking time in caring for them, prompt responses to their concerns or issues, accessibility, encouragement and recognition that this was exciting and frightening all at the same time. 
For those who were unsatisfied and somewhat unsatisfied the most common aspects identified were the attitude of staff towards them, poor communication including a lack of active listening to the needs and concerns of the women, judgement, a lack of support around breastfeeding and a lack of time to spend with them particularly in the home setting. 
Key Themes of Post-Natal Care Consultation Findings:
Access to post-natal support and services
Post-natal supports were a surprising area of feedback given during the consultation process because of Canberra’s size and the positive history of our service delivery system such as Mid-call and Maternal And Child Health Nurse home visits and availability in community settings. Despite this, women felt that they did not have access to enough post-natal support. A range of issues and perspectives were provided to the consultation 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 breastfeeding support, early parenting adjustment and child health support.
Women talked about being in hospital for 24 hours or less and that they would have preferred a longer hospital stay to ensure that their milk had come in, that they got through the ‘baby blues’ period and had access to support 24 hours a day for the first week. 
From the information that women gave us we can also surmise that there may be a reduction in the workforce knowledge and skills where there are shorter hospital stays. Breastfeeding is an example -  where women are experiencing shorter stays in hospital, the workforce skills and knowledge around breastfeeding decline and in that hospital environment staff may not be confident to support her because they have not seen enough breastfeeding to feel confident themselves. Equally there is a corresponding need to ensure that maternal and child health nurses are adequately trained to pick up on the issues that were previously resolved within the hospital setting during long hospital stays.  
It was clear that for women there needed to be different arrangements in place following birth. Women spoke about their discharge and how this could have been better if they had had more visits from MACH 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 help them develop confidence. Other women reported they felt rushed, that their questions were not answered and that they needed more information from the nurses during this time. 
Within this consultation there was a notable difference of the experiences between women who had been sent home within 24 hours of birthing and those who had stayed longer or who received what they perceived to be adequate home visits from a MACH nurse. There was consensus that the model of home visiting is worthwhile and extremely valuable, but feedback through the consultation was that the capacity of MACH nurses to respond and work with new mothers was not adequate in all situations. This could be because the original intent of the postnatal supports provided to women through the home visits model has shifted and changed due to practices such as shorter hospital stays. It could also be argued that there has been an increase in the expectations of mothers to be able to access support, information and monitoring of themselves and their child because of the shorter interactions some of them may have with midwives in the hospital. 
With these ideas in mind it is important for the system to reflect on current models of postnatal supports and service provision and adapt the model to the current environment and women’s reflections on their experiences. Providing women with access to a highly skilled and well-resourced postnatal support system provides long term social and health benefits as well as fiscal savings for the overall health system. This is possible through examples such as shorter hospital stays post birth, reductions in readmissions to hospital and other entry points of the health system as well as reduced costs of women accessing mental health services.
Women described some helpful postnatal experiences:

He was born first thing in the morning and we stayed that day and the next day and then went home the following day and everyone was just fantastic for the whole time and I got heaps, I think maybe because we were there for quite a long time comparatively to those who have to go home the same day or the next day. 

I stayed in hospital a few extra days during that time when it is so important to get that extra help. The staff were really, really good. We called a couple of times but honestly there were staff coming in and out all the time. We would just ask who ever happened to be there without even knowing what their position was and everyone had lots of time for us. They all seemed happy to stop and help for 10 mins or half an hour or they would send someone else. So I got lots of help and was really happy. 

We had to wait for a bed, on the second morning they said how are you going, do you feel happy about breastfeeding and looking after yourself and the baby at home and we both said no. We were both a bit shell-shocked at what had happened. She said she needed the room because she obviously had someone else that 10 times over she could have put in that room but she let us stay there for those extra days and I was really grateful for that. 

I stayed in hospital for what I recall was four nights, where I received assistance with breastfeeding and care of myself and my baby. I was very happy to be staying in hospital to recover after the birth as I felt sore and vulnerable and also was unsure with breastfeeding. After hospital I had a visit from a MACH nurse who looked over my son and also gave me advice on breastfeeding and other things

Bub was born at 6am and we stayed another 2 nights In hospital. We were told we could stay as long as we needed and it was our choice how long we stayed for which made me feel better about it all. Bub was feeding really well before we left hospital. I had a visit on the second day home, phone call on the third day and another visit on the third day. Bub was doing so well that the midwife said she wouldn't come back unless I called and I never needed to call her. Bub was feeding and sleeping well and I seemed to know what I was doing. My husband was at home with me for 6 weeks after we had our baby and we have all our family and friends close by.

For myself I had the one home visit from the MACH nurse which was useful, but I was more supported by my GP who was assisting with ongoing pain I had from the c-section scar after discharge.

Midcall visited us for four consecutive days after we went home and offered comfort and reassurance that we were putting the skills we had learned in hospital in practice correctly. We were clueless but managed well in hindsight. After I was formally discharged, the ACT MACH nurse visited once to let me know if the ongoing and extensive support network available to me from there on in. We attended a check-up at the baby clinic when my son was one week old.

We stayed in hospital for 5 days and this was vital for us to have been successful in breastfeeding. We had a midwife/lactation consultant with us for every feed and we needed that support! Bub was small and we had attachment and supply issues. They have us an urgent MACH nurse referral and she came to see us in the first week at home who recommended we see our GP/lactation consultant for more help with supply. These 3 things were vital in the success of our breastfeeding and growth of our baby. We also received info on post-natal depression, care and contraception before leaving hospital.

The care in NICU and Special Care was amazing. It was a difficult time, but everyone was amazing. After I was discharged from Post-Natal, we were accommodated at Ronald McDonald House, so we could keep breastfeeding our daughter. That was also amazing.

Once we got home my midwife visited regularly (I can't remember how often). I felt very supported and cocooned in our home with my Mum staying for the first 3 weeks as well. 

We stayed 4 days on the postnatal ward at The Canberra Hospital, as my baby needed some antibiotics. We had a single room so my husband could stay. This was really important to me, as I think it is really important for the family unity to be able to stay together post birth - not only because we needed to support each other, but it really helped my husband to bond with the baby in those first few days. We were seen by midwives, physios, and the medical team. Our baby was given some antibiotics due to some high temperatures, but we were both otherwise healthy. I cannot speak highly enough of the doctors, nurses and midwives that cared for us. The facilities at the new hospital were also wonderful. We were assisted with breastfeeding while we were in hospital, and it was all going well. We were discharged on day 4 feeling really confident.

Women described some unhelpful postnatal experiences: 

I wish I had been able to stay in hospital until my milk came in so I could establish breast feeding.

I found the post-natal care in the hospital varied a lot. 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.

I felt the nurses were short staffed and over worked. Particularly after a C-section where you are unable to get out of bed for 24hrs it is difficult with very little support to help look after the baby. I was also very unsure about post op recovery for my C-section. The whole time in the hospital I was not seen by a Dr after surgery and nothing was explained to me. 

When I came home I was told a MACH nurse would visit in the first two weeks. I was phoned twice and told no one was available to come to my house. On the second call, I was told if I wanted to see a MACH nurse there was only one appointment available in Narrabundah (I'm in Tuggeranong) in 2 hours’ time. I was at home alone (my partner returned to work when I got out of hospital) and desperate to see someone about my baby, so I attended the appointment (my baby was 10 days old). I was on my own and it was the first time I left the house since coming home from hospital. Due to such short notice I was unable to arrange for someone to help me. When I was at the appointment the MACH nurse scolded me for driving 10 days after a caesarean. I felt that the system had let me down.

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. The midwife on day 3 helped tremendously and without her intervention our son would have needed to go back to hospital. She returned on day 5 to check on his progress. I had major feeding issues for the first 2 months, had nightmares and flash backs about the birth and had no family in Canberra. I eventually discovered by Googling the community health centres and saw a MACH nurse for feeding issues.

Once we went home we received 1 house call when at 9 days old. Our baby had dropped weight but nothing was done or suggested to me. The next few days he wasn’t as responsive and I took him to see a GP where we discovered he had lost a total of 700gms. We were admitted into the Canberra Hospital within the hour.

The midcall midwives visited me every day for nearly two weeks during which time it was found my daughter had a tongue tie. We went back to the hospital within a week to get a tongue tie snipped. This did not help and personally I found the whole process distressing. 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.

Initially we received helpful care at the hospital and then at home from out midwife/s. We settled quickly into our life with our baby. Things began to fall apart 2 days before we were discharged from the program. We felt that we were rushed out just when we started having problems because it was Christmas. We were having ongoing feeling problems and I developed mastitis and then a breast abscess. My son was later diagnosed with a tongue tie.

I went home after 2 nights in hospital. We live in NSW so don't have mid call. My milk hadn't come in, so I did have trouble with breast feeding initially. My friend who's a midwife came and helped me, due to her help I established breast feeding and had a nice settled baby

I had to follow up myself on a midwife visit who didn't come until I think 4-6 weeks after birth. I went to the Early Days clinic very early on because of breastfeeding difficulties. They tried to help but I had to push through myself. My baby also had colic so it was a very hard time.

Breastfeeding support
Breast feeding was raised as a major concern for women in the post-natal care period, and in particular, many women suggested the need for greater professional support in initiating and establishing breastfeeding, including greater access to support from midwives, particularly those trained as lactation consultants. Women talked about receiving information about breast feeding being a natural process that was the optimum for their child’s development, and with the birthing experience women reported that they felt an enormous amount of pressure to breastfeed and “get it right”. However, many 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 understood that midwives on the wards were busy but would have preferred the midwives to be able to stay and watch and advise during the 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 they reported that this had an impact on their mental health during the formative stages of their relationship with their baby. Some recited how years after the event they still feel like a failure, particularly where babies had been diagnosed with failure to thrive in the early weeks of life. 
The 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 the community support options and access to lactation consultants. 
Women said: 

We got lots of information on breastfeeding

A friend of mine recently birthed and she was told that breast is best and she was made to feel bad because she needed to feed him formula because her little boy was not well and he was in special care for a while. She told me I am pumping and I am doing the best I can and every nurse that came in said to her “Why are you giving him a bottle?” because they hadn’t read the notes and so like every time there was a shift change they were asking her why aren’t you feeding him? So she was forced to explain again and again why she was doing these formula top ups. 

I found that every education session I went to and every pamphlet I was given and I raised this with the hospital when I was discharged and they said we don’t like to dwell on the negative and I said well a large proportion of us find it difficult or can’t breastfeed like the pamphlet says, so may be some more information about when things don’t go well or things don’t go to plan.

Nurses kept on providing inconsistency between how they do things which made things extremely stressful which did not help with trying to increase my milk supply.

After three days I knew I was meant to leave but nobody had spoken to me about what was to happen. 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.

The best thing was having a midwife show me my file notes and explain exactly what had happened during the birth, which helped me enormously in coming to terms with it.

My midwife was caring but it didn't help me to feed. She did a urgent referral to MACH but wheb the nurse came out she just have me pamphlets - which wasn't going to help me feed.

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. My baby cried almost constantly from lack of food and it was only later in my stay (day 3 or 4) that one of the midwives suggested formula as an alternative and I was too scared to ask.

I had trouble getting a good attachment after I went je and my milk came in properly and even though the MACH nurses at Queanbeyan were really helpful, it still wasn't going well . I ended up seeing a lactation consultant called Ingrid when bub was 10 days old and it was the best $170 I ever spent! She worked out that I did the baby led attachment he got a much better latch and breastfeeding became so much easier for us both!

Access to Post Birth Information
The majority of women noted that although they had received some information prior to the birth of their child, with  the written information they received following the birth was difficult to find the time to read and that they often did not find out about the services that could have helped because they were included in a bag containing commercial products. As a result, they did not discover the community services information until much later – often 10-12 months following the birth. 
The women spoke about understanding that everyone has different levels of knowledge and understanding when it came to post birth information and that it was important to check in on where individual women’s levels of knowledge and understanding were at. Women gave examples of this in relation to caring for themselves following the birth for instance with wound care and breast care and also about some of the basics to do with caring for a baby such as bathing or settling. 
The other 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 advice on what information on the internet was good and links to some of the better national information around their postnatal options.
Women said: 

A lot of the information I found was through social media it wasn’t through any sort of formal avenue it was just through you know, for example, you know on Facebook there were groups that would have that kind of information for you to just browse and yeah there were forums and things like that. That is pretty much how I found out my information. 

After the birth we got lots of information and they took care of my tear and showed me how to keep it clean. I couldn’t fault them. 

….they need to be make sure that they recognise that and give the right information, give the right services. If I had been transferred quicker …..I probably wouldn’t have had half the issues than I already had

One thing was I felt I left hospital not knowing much. My baby was attaching well but I didn't know she wasn't getting any milk so 4 days later we had to go back to hospital because she had lost too much weight. I didn't know how to bath her for the first time. Just a few things I would have appreciated knowing.

First few days visited by the partnering midwife. It felt like she rushed through information and told me my midwife would fill me in. No options given for any trouble with breastfeeding which she thought was ok, despite me describing what was going on. She also gave me contradictory information to my own midwife

I left hospital on day four post caesarean and had been given no post caesarean care advice from the hospital.

Discussion of key themes
Four overall themes emerged from the analysis of the three key areas of pregnancy, birthing and postnatal care that were raised by women in the survey and in the focus groups. The four themes were information provision, the ideal experience, choice and involvement in decision-making and improvements to models of support and care. 
Information provision
Within the theme of information provision, overall women advised that there was a lack of information available for women in the ACT and, while we know that women in the ACT have access to an infinite amount of information on the internet, it would still seem that the local place based information they would like is unavailable or not available in one spot. This is an important issue for the women because they wanted to have the ability to compare and contrast what was available within each hospital and what the different models of care offered. 
Women’s feedback was clear about the lack of information available about the models of care available in the ACT. The role of family and friends was clearly evident as an important source of information to fill in the gaps in this area, and this reinforces the need to have an accessible, accurate and trustworthy source of local information that is adequately promoted. This would ensure that whether it is a woman, a professional, or her family members or friends, everyone can safely refer to one source of information and be confidently assured that women will get the local information they need. 
In regards to information during the birthing experience, women reported that they wanted to understand more about the spectrum of experiences that could occur during the birth. The information about vaginal births is important and relevant and is perhaps being focussed on in an attempt to reduce intervention rates. However, the lack of information about the complications that may result in the use of interventions such as forceps, vacuum and caesarean deliveries and their impact was reported by women in the consultation as causing stress during and after birth which has long term impacts on their transition to motherhood.
Breastfeeding featured throughout the survey and focus group responses and the consultation found that women would like to see more information provided that is honest and realistic about the different types of experiences women may experience. Women also raised the issue of conflicting information about breastfeeding from the practitioners they were engaged with. While some women were confident enough to take some advice and leave other parts, for those who were feeling vulnerable or that they were not capable, the increased confusion from conflicting advice had deep impacts. 
Ideal experience
Women told us that they would like to have more information about the spectrum of experiences that can occur during birthing in particular. This is linked to the concept of the ideal experience, which emerged as the second major theme within the consultation. At all stages of women’s pregnancy, birthing and post-natal care they spoke about how the ideal experience was presented as being dominant and ‘normal’. Whether that was about a healthy pregnancy with no complications, or a vaginal birth as good and a caesarean birth as bad or that breastfeeding was the only option, women who were somehow unable to meet the benchmarks felt judged, guilty and defeated before they had even begun. 
The ideal experience was also linked to the issue of trauma within birth for some women. Where women had only been presented with the ideal experience and then their birth subsequently was not ‘ideal’ there were perceptions that they were failures and they found it difficult to resolve the traumatic experience following the birth. Therefore, there is a need to provide women with access to debriefing about their birth experience which could include explanations of their notes and referral pathways to professional services. 
Choice and involvement in decision-making 
Women’s experiences of choice and involvement in decision-making was highlighted as a theme across all three of the stages of pregnancy, birth and postnatal care. Women were aware of the importance of decision-making about the maternity care they received. The women’s stories conveyed how poor involvement in decision-making could have lasting impacts on the health and well-being of the women, child and her family.
It is important for practitioners to convey whether there is a clear, well-supported rationale for having any procedure, drug, test or treatment. In the examples given by the women of care settings where medical interventions were used and the women were not included or even had the rationale behind the decision communicated to them, women felt disempowered and left to understand ‘why’ by themselves. 
The key to women knowing and understanding the ‘why’ behind the decisions that are made with them was communication. This was a repetitive theme amongst the participants who expressed their belief that when people took the time to communicate with them they would have experienced more positive outcomes and had clearer understandings of what was happening in relation to their body and child. 

Improvements to models of support and care
The need for communication was also linked to the final theme from the consultation - improvements to models of supports and care for women during pregnancy, birthing and postnatal periods. In the first section of the survey women identified the facilities available within Canberra as part of the initial considerations for their choice of where to birth. The consultation also revealed that women’s levels of satisfaction was actually linked more to the people who were part of their care team and the practices that they used to make women feel empowered, comfortable and safe. 
Most women preferred midwife led care and where they were not satisfied with that, it was because the continuity in their care was broken, usually by the midwife not being available for the birth. The security and confidence women felt when there was a midwife available to them for the duration of their pregnancy and birth was strong and directly related to how successful women assessed themselves as being when giving birth. 
Continuity of care was also expressed as a positive factor beyond the scope of the midwife relationship. Where women reported feeling good about their care it was linked to the relationship they had formed with their practitioner including Obstetricians and General Practitioners. Continuity of care is not a new concept and works for women therefore it is important to ensure that this remains a central concept during pregnancy and birth but also into the postnatal stage of motherhood. 
For the women who experienced positive interactions with the postnatal home visit model, there was an immense amount of praise and gratitude for having a service that was able to provide support within their home following discharge from hospital. For other women the concern wasn’t about the model itself it, but about the elements of how the model operates. In particular, the number of visits allowed, the amount of time MACH nurses were able to spend with them each visit and the levels of knowledge and style of communication that some of the MACH nurses. In general women would have liked more visits to assist them with transitioning into motherhood and, especially for those leaving hospital early, assistance with breastfeeding. 
The levels of knowledge of MACH nurses was also linked by the women to their feelings of confusion because they reported receiving conflicting advice between nurses and midwives, obstetricians or GPs. At times this was interpreted as MACH nurses not having enough knowledge in this area. Of course this could also be influenced by MACH nurses being time poor and not having the time to thoroughly answer questions or concerns. This in turn may have an influence on the style of communication MACH nurses used when working with new mothers who may be sleep deprived, unsure of themselves and worried about their child and how it is all going. 
These examples of concerns from women demonstrate a cycle of practice that for some women can feel particularly isolating and not helpful. With review and improvements to the current supports and care for women, this model could adjust to operate more effectively to provide increased positive outcomes for women in the ACT. 

Conclusion
Overall the consultation was rich and provided valuable insights into the lived experiences of a group of women in Canberra and the surrounding region about their experiences as they progressed through their pregnancy, giving birth and during post-natal care periods. The consultation process enabled them to relay their experiences and identify what worked and what could make a difference to the experiences of other women in the ACT community. 
It also enabled women to give their perspective on the issues which are most important during this time in their lives. Providing a safe environment for sharing personal stories is important for women and allows the design of service responses and advocacy to be informed by their contributions. 
The findings of this report highlight several areas of future work that we hope will assist in helping the ACT Government, maternal health providers and the range of other services provided to pregnant women in the Territory to improve the experience and health outcomes of women and their transition to motherhood.