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University of Technology Sydney. Faculty of Health. Background: Homebirth is an uncommon event in Australia, with only 0.3% of all births occurring at home. Despite this low rate, there is evidence of consumer demand for out of hospital births. In order to meet this demand, 14 publicly-funded homebirth programs have been established in Australian maternity hospitals over the past two decades. Aim: The aim of this study was to explore midwives’ experiences of providing publicly-funded homebirth in Australia. Methods: Twenty one semi-structured interviews were conducted with midwives and midwifery managers who had recent experience of working in publicly-funded homebirth programs. A constructivist grounded theory approach was taken to enable exploration of the underlying social interactions and processes in the area of inquiry. Findings: Four overarching categories emerged from the data. These were: ‘Making the leap from hospital to home’, ‘Seeing birth in a new light’, ‘Building trust’ and ‘Recognising the benefits of publicly-funded homebirth’. Hospital-based midwives who were exposed to homebirth for the first time found their perspective of birth was transformed. Midwives noted a shift in the power dynamics when on the woman’s territory and many felt they were witnessing undisturbed birth for the first time. Midwives and midwifery managers faced challenges in establishing and maintaining publicly-funded homebirth programs. They needed to develop strong, collaborative working relationships with doctors and endured a high level of scrutiny regarding their practice. Overall, the majority of midwives enjoyed working in the model and felt it helped normalise homebirth as an option for low-risk women. Discussion: Homebirth has previously been regarded as being both geographically and ideologically distant from the hospital. The operation of publicly-funded homebirth programs, however, defies this characterisation by providing a homebirth service via public maternity hospitals and hospital-based midwives. The establishment of publicly-funded homebirth programs within Australian hospitals appears to have had a positive effect on attitudes towards homebirth, not only for women and midwives, but for allied healthcare providers who were previously mistrustful of homebirth. Conclusion: The transition from hospital-based to homebirth care provided an opportunity for midwives to work to the full scope of their practice. When well supported by colleagues and managers, transitioning into publicly-funded homebirth programs can be a positive experience for midwives. Additionally, exposure to homebirth has the potential to transform maternity care provider’s attitudes towards homebirth and significantly deepens their understanding of normal physiological birth.

University of Technology, Sydney. Faculty of Nursing, Midwifery and Health. Background: In 2008, a national review of maternity services was commissioned by the Australian Government. A number of significant reforms to the funding, organisation and delivery of maternity services were proposed with the stated intention of improving women’s access to high quality, safe maternity services. A community consultation process was undertaken as part of The Review, inviting interested parties to comment on the proposed reforms. Over 900 individuals and professional organisations responded. Aim: The aim of this study was to uncover the perceptions, beliefs and meanings associated with childbirth held by the key stakeholders in Australian maternity care. Methods: Discourse analysis was chosen as the methodology for this project as it enabled examination of the unspoken or hidden messages in the data, paying particular attention to the construction of childbirth and the manifestation of power relations. The data set comprised of 11 submissions from peak professional and consumer bodies to the National Maternity Services Review (MSR). Findings: The expression of, or desire for, power and control was found to be the major discourse underpinning all of the submissions analysed. In the context of maternity service reform, this discourse confirmed the existence of fundamentally different constructions of childbirth by the key stakeholders. This resulted in diverse opinions on how maternity services should be managed and operationalised. A discourse of risk and safety was used by the peak medical bodies to argue against the majority of proposed reforms. In contrast, peak nursing, midwifery and consumer groups used language that constructed childbirth as a normal life event. As such, submissions from midwifery, nursing and consumer groups demonstrated strong support for the Government’s reform agenda, arguing for a new vision for the future of maternity care that placed the childbearing woman at the centre of care. Discussion: A clash of ideologies was evident amongst the key stakeholders in Australian maternity care. The fundamentally different constructions of childbirth possessed by obstetricians and midwives (supported by nurses and consumers) support the notion of ‘turf wars’ in the maternity care system. Whilst midwives and obstetricians already work together collaboratively, it appears that their interactions are often underpinned by the ‘politics of power’. The findings of this research raise important issues around power and control in childbearing. They raise questions about women’s right to have control over their bodies in childbirth – including decisions about their most suitable care provider, model of care and intended place of birth. As long as the struggle for power underlines the actions of care providers, women will not truly be at the centre of maternity care. Conclusion: Understanding the different ideologies inherent in the professional and public discourses of childbirth provides insight into how each party can work together more effectively to ensure the delivery of high quality maternity services for Australian women. The encouragement of professional courtesy in practice would go some way in ameliorating the ‘politics of power’ that underpin maternity care providers’ interactions. Changes to the way medical and midwifery students are educated, including greater exposure to normal birth, is required. Further research into the socio-cultural meanings associated with birth is warranted as developing greater awareness of the different constructions of childbirth supports harmonious relationships between maternity care providers.