Remembering our wartime nurses
Think:Health cultivates and articulates the best in health research and news.
The following episode, which aired on Sunday 24 April 2016, features:
- new research finding midwives and obstetricians feel guilty following a traumatic birth (01:10);
- an evaluation of the cost of hospital versus homebirths (9:55); and
- stories celebrating the work of WWI nurses (18:42).
Academic guests:
- Katja Schrøder - PhD student from the University of Southern Denmark
- Rachel Smith - Lecturer at the UTS Faculty of Health
- Vanessa Scarf - PhD student from the UTS Faculty of Health
-
Dr Kirsty Harris - Researcher from the University of Melbourne
Host/s:
- Ellen Leabeater, 2ser
- Ninah Kopel, 2ser
START OF TRANSCRIPT
Ellen: Hi. Welcome to the show. Ellen Leabeater with you. Today we're pitting home birth against hospitals to see which one is the most cost effective.
Vanessa: But there is often the argument that to provide care for women out of hospital is more costly, but we actually don't know what. So what are you attributing that statement to?
Ellen: And a look into the contribution Aussie nurses made during World War I. But first on the show.
Katja: An older midwife once said to me we all carry a child around with us. We all have a story to tell about one particular child or family when things went really bad.
Ellen: Birth is rarely as easy or straightforward as you'd like it to be. However, in the vast majority of cases, baby and mum come out the other end feeling fine. But what happens when your birth plan goes south, and suddenly what was meant to be an uncomplicated birth becomes an emergency?
Katja: I thought is that so? Because we don't talk about that very often. Hi, I'm Katja and I'm a registered midwife and a PhD student.
Ellen: Katja is from the University of Southern Denmark and has been looking into the impact traumatic births have on midwives and obstetricians. How do you define a traumatic birth?
Katja: In this study, we have defined traumatic childbirths as events where the infant or the mother suffered presumed permanent, severe and possible fatal injuries related to the birth. So these are actually what you might call the worst case scenarios of a childbirth.
Ellen: So a traumatic birth can include things like the death of a mother or baby. It can also be something like perinatal asphyxia, which is when the baby doesn't get enough oxygen, or some sort of procedure is performed on the mother without her consent.
It is traumatic for the mother and baby, but it also takes a toll on the midwives and obstetricians who are part of their birth, although we should stress that this happens in very few births in the western world. Katja says the number is around 1 per cent to 2 per cent.
Katja: These events are very rare in our part of the world, in Australia as well, and this would be below 1 per cent or 2 per cent, depending on what you put into this definition of traumatic childbirth.
Ellen: Traumatic births are caused by a range of things, from the health of the mother to where a woman gives birth. Katja says it's important to emphasise that traumatic births don't necessarily come from error.
Katja: No, I think it's very important that we remember or emphasise that not all traumatic births are caused by error, and far from all events can be easily distinguished in error or non-error. So when we work as healthcare professionals, although in our part of the world we are highly-educated and highly-trained and we are evidence-based and so on, still we have to, in every clinical situation, make an estimation or assessment of what is the best thing to do in this particular case.
Being that none of us are able to look into the future, sometimes we find out in retrospect that we could have done something differently and it might have had a different outcome then.
Ellen: Rachel Smith is a midwife and lecturer at the University of Technology Sydney. She says that women are more likely to experience a traumatic birth if they don't have a good relationship with their care provider.
Rachel: We do know that women who birth within the system and also women that don't know their caregiver are probably more at risk of traumatic birth experiences. We know that women who are able to know their care provider, build a trusting relationship with them, are more likely to be satisfied with their birth, regardless of the outcome of the birth.
Ellen: Katja has surveyed over 1200 midwives and obstetricians to find out about their traumatic birth experiences. She found that a third of those who were present at a traumatic birth felt guilty afterwards.
Katja: What is one of the main findings is that more than one third agreed that they would always feel some sort of guilt when thinking about the event, and this could even be in cases where no blame was placed because they had done nothing wrong.
Ellen: Interestingly, 50 per cent said it made them think about the meaning of life.
Katja: I think also another main finding is that as many as 50 per cent agree that the traumatic birth had made them think more about the meaning of life, and this tells us that the healthcare professionals involved are affected not only professionally but also at a personal and even existential level, I suppose you could say.
Ellen: But does this translate into practice? Well, yes and no.
Katja: Actually, 65 per cent agreed that they had become a better midwife or doctor after this event, so they take some kind of learning with them, which I suppose is a positive thing, but maybe we - again, we have not been able to see what kind of learning is this.
Maybe is that just again some kind of meaning-making for themselves, because at least something good had to come of this, at least I learned something and I won't do this particular thing again.
Others in the interview study said well, I can't - you cannot transfer every learning experience, because the next birth is a different situation.
Ellen: Rachel agrees, and said midwives and obstetricians will often dwell on a traumatic birth. She says they often lie in bed at night thinking what if?
Rachel: There wouldn't be a midwife or an obstetrician or anyone that works around birth that hasn't had sleepless nights around could I have done something differently, was it something I did that made this event occur, those sorts of things that wake you up in the middle of the night.
Ellen: The ongoing trauma could, in part, be because of the poor support offered after a traumatic birth. Both Katja and Rachel criticise the ad hoc approach to debriefing following a traumatic birth.
Katja: I think this varies, and in some departments they're probably better at taking care or offering support, but what we found in this study is the general picture is that the midwives and obstetricians feel that they don't get as much support as they probably would like and that there is a certain sort of professional culture that we are - I suppose we're trained to be able to deal with this, and we have no place to turn, really, to find more support.
Rachel: Usually the system will provide a method of debriefing around that traumatic experience, but that's not always done overly well, and given the way that the structure of the system that they're - that you may be exposed to this traumatic event and then not be on duty again for another two days or three days, and you come back on night duty and you miss the debriefing meeting.
So there's not always a great process of ensuring that some debriefing and some supported reflection occurs around these traumatic situations.
Ellen: Apart from now knowing that midwives and obstetricians need more support, Katja says people are relieved that these discussions are finally happening.
Katja: We've had loads of responses in the survey, you know, at the end, when there's an open end do you have any comments for this survey, and loads have just responded that they were so happy and appreciative that we did this survey, because they felt that this is not very acknowledged that they struggle with these kind of things.
Ellen: Coming up next, how much does the place you give birth in cost? You're listening to Think Health on 2SER 107.3, on demand at 2SER.com or on your favourite podcast app.
Could encouraging more women to give birth at home save taxpayers' money? Overseas studies costing the place of birth seem to think so, but no one has crunched the numbers here in Australia.
Midwife Vanessa Scarf is the project coordinator for the Birthplace in Australia study at UTS. She's looking at the comparative costs of giving birth in domestic or hospital settings in New South Wales as part of her PhD. Vanessa spoke to Ninah Kopel.
Vanessa: We need to, as well as we can, quantify the cost of giving birth in settings that are out of hospital, to add weight to the argument that these are not more expensive settings when appropriately provided for women. We can save money, we can improve women's and babies' outcomes, and we can make it better, make it better for women who don't want to choose to have their baby in a hospital.
Many women don't want to have their baby in a hospital setting but have no other option.
Ninah: What kind of cost difference does that bring into the equation with births, between a hospital and another setting?
Vanessa: When you're performing a cost analysis, the perspective has to be taken into consideration. For my study, I am most interested in the cost to the health service, largely because there's been no quantifiable costing of place of birth - and I'm focusing on New South Wales - but there is often the argument that to provide care for women outside of hospital is more costly.
But we actually don't know that. What are you attributing that statement to? It costs nothing for the midwife to go to a woman's home in terms of the actual place of birth. A midwife who performs home births or attends home births, I should say, has to take equipment, so there are costs to her. There's emergency equipment, there's the general equipment for attending a birth, including delivery things.
So in New South Wales we have two publically-funded home birth services, as far as I know. That number changes frequently. So that would be a cost to the health service. So the health service provides the midwife, provides the equipment, and obviously the salary for the midwife. So there are two sides to the home birth story in New South Wales.
Ninah: What does the rest of the world tell us in terms of the cost difference?
Vanessa: In the studies that I found - if you think about it, in low and middle income countries, birth at home occurs most of the time and with not good outcomes often because these women are not necessarily attended by skilled birth attendants. So just for this argument we're going to leave that area aside.
So for high resource countries where there are choices for women to birth away from a hospital setting, in the 11 studies that I found that did specific birth setting costings, eight of them found it was much less expensive to have a baby either at home or in a birth centre.
A birth centre is a setting that can either be situated away from the campus of a hospital completely, which is where you refer to those as freestanding birth centres, or there's a birth centre that is situated either in the campus of a hospital that provides obstetric care, including operating theatre facilities. So it can either be actually next to the birth unit, a couple of rooms that have been designed with a more home-like sort of look.
Ninah: And then the alternative, then, is homes?
Vanessa: Yes, so there's the birth centre or there's home. So the free-standing birth centre is also a home-like environment, but a woman who needs to have higher care, needs to actually be taken from that setting to the hospital, either in an ambulance or a car.
Ninah: So there's some sort of assessment that would take place to determine higher-risk birth situations, and they would then be suggested to go to a hospital still, as opposed to a home birth, regardless of the cost?
Vanessa: Absolutely. That's a really good point that you've actually just made. We're talking about women - healthy women who have healthy pregnancies, who we don't foresee are going to have any problems in their labour. We screen women at the very beginning of the process, and ideally these women are looked after by the same midwife throughout their pregnancy and they remain healthy.
We know that there are many issues that can arise during pregnancy, including short- and long-term health conditions like diabetes, blood pressure issues, so those women, even if they start in a home birth or a birth centre preferred setting, will be referred to the hospital if they become unwell.
Ninah: How many women are currently deciding to have their babies at home?
Vanessa: Only around 0.3 per cent to 0.4 per cent of women actually have their babies at home with a midwife attending, and we don't include the women who accidentally have their babies at home, because they didn't plan to have their babies at home and they are of varying risk status, for want of a better term.
We always want to look at women who are healthy and at low risk of any pregnancy or medical complications.
Ninah: So you're talking about the cost to the public purse, but from an individual's perspective, does it cost more to have your child in your home? Are there things you have to buy or things to prepare that you wouldn't have to do if you were going to a hospital?
Vanessa: Yes, and that also depends on the kind of service that you have available to you. So if you're engaged with a publically-funded home birth model, there may be some equipment that you may have to purchase - and look, I'm not entirely sure about this.
Many women like to give birth in a pool, so some women may need to purchase the birth pool to have in their house. It may be provided by their midwife. These are small details that I actually don't know yet, but I will be finding out.
But women who engage in a privately practicing midwife pay them a fee, pay them a fee like they would pay a private obstetrician, and these midwives now have Medicare scheduling benefits, but there is still an out of pocket cost, as there is to engage a private obstetrician.
Ninah: Going forward with the research that you're doing, is the goal to develop a collection of numbers you can then take to government to show them the cost benefits?
Vanessa: That's definitely what we hope to do. The thing about this is that women want choice. Women want more choice in where to give birth, and we know that not only is it safer for many women to have their baby outside of the hospital setting, the benefits are much more far-reaching than just a live mother or a live baby at the end of them.
There's a lot of research coming out now about actually the mode of birth is significant. I'm sure many people have heard about the microbiome and when a baby is born through the vagina it actually naturally takes on a whole lot of bacteria that the baby needs to set up its gut for it to have a healthy gut, and they're connecting gut health with psychological health and all sorts of really far-reaching health benefits into the future.
Some people will roll their eyes and go oh, that just sounds like a really far-fetched notion, but if you think about it, biology is an incredibly powerful thing, and if we biologically were meant to be born through a bacteria-filled passage, then there's a reason for that.
Ninah: And homes will provide that, you think?
Vanessa: Vaginal birth provides that, so homes provide it, birth centres, birth in a birthing suite in hospital, absolutely. So when we're talking about mode of birth, there are many far-reaching consequences. The mother's psychological reaction to her birth experience, it can be very impactful on their health going forward with their baby.
Ellen: Nine Copewell speaking there to Vanessa Scarf.
Quote: You're listening to Think Health on 2SER 107.3.
Ellen: Monday 25 April marks the 101st anniversary of the ANZAC troops landing on Gallipoli. But it's also a time to remember the work Aussie nurses were doing behind the scenes to treat wounded soldiers. From administering anaesthetic to teaching doctors how to use x-rays, a relatively new technology at the time, nurses were an invaluable asset to the Australian army.
Dr Kirsty Harris is from the University of Melbourne and has spent copious amounts of time researching nurses, all because her grandmother was a World War I nurse.
Dr Harris: So my younger sister who's a trained nurse wanted to know what Gran had done during the war, and she was asking from a professional sense. Was she a theatre nurse or was she a ward nurse? Did she have a specialty? So I said I'd find out, and that turned into many, many years of work.
It’s a bit sad, we don't really know what Gran did. There's not the records to show that. But I'm very proud of the fact that I've been able to discover how extensive the work that nurses did in World War I.
Ellen: So Kirsty, how many nurses actually served in World War I?
Dr Harris: It's quite difficult to tell how many Australian nurses served, because they didn't just serve in the Australian Army Nursing Service, but also served in other organisations, including the two British military nursing services. So my best guess at present is around about 3000 may have served, but I and other researchers are constantly still finding names of people who did go off and serve, so we're not entirely sure.
Ellen: What sort of conditions were the nurses working in?
Dr Harris: The nurses served in 15 different countries, some countries where there weren't even any Australian infantry troops, such as India and in Salonica and Greece, and conditions varied very widely. Salonica was a very brutal posting because of the weather conditions and the fact that nurses lived in tents. Lemnos, during the Gallipoli campaign, was also known for its hardships for nurses due to lack of supplies and poor accommodation and food.
But if you were, say, posted to England, you were probably in quite good conditions and very much like being in a hospital at home. If you were in a casualty clearing station on the western front where you might have been only 10 miles behind the fighting, then you were, again, under canvas.
You could have been working in France in the middle of the worst winter for 40 years and had all your medicine and all the water frozen and made it very difficult to prevent patients getting frostbite and things like that. On top of that, you probably were getting bombed as well.
So conditions were very varied, depending on which climate and which country you were in.
Ellen: Do we know if any nurses were casualties during the war?
Dr Harris: Certainly we had eight nurses, seven in the Australian Army Nursing Service and one in the Queen Alexandra's British military service, who were awarded military medals for their bravery under fire. I know of at least three nurses who sustained injuries, like soldiers did, from pieces of shrapnel and so on. So we did, but we didn't have anyone die from wounds during the war. All the nurses who died during the war were due to sickness.
Ellen: What sort of women became nurses? Was it conscription or was it a voluntary thing?
Dr Harris: Oh, it was very much voluntary. Putting your hand up to go to war - at the beginning of the war, almost every trained nurse, apparently, put up their hand to go. It was a very desired thing to be offered an appointment with the service overseas.
A trained professional nurse meant someone who had done three or four years' training under an auspice course in a general hospital, and if you were a career nurse, and nurses did have careers back then, that was where the action was, to go off and to be at war where you'd be able to use your skills and develop your skills to help people who were really in need of that kind of nursing, professional nursing assistance.
Ellen: So it was really exciting to go off to war as a nurse?
Dr Harris: Well, I think nurses in the early days shared the same sort of sentiments as the soldiers. They went for nationalistic reasons, to do their duty. I think one nurse said I thought I would learn more, and by gum, I did.
Of course, when casualties started being reported in the newspapers and wounded, badly wounded people came back to Australia, then some of the excitement and adventure feelings obviously would have decreased, but for many nurses it was a chance to leave Australia and see the world, and they really wanted to play their part.
Ellen: Nurses, of course, during this time they weren't just doing what we would think of as typical nursing duties. They also did other things. Can you tell us a bit about that?
Dr Harris: The nurses had to learn to take on roles because of the lack of doctors to do the roles, so nurses became anaesthetists, they were assistant surgeons in theatre, they dispensed drugs, they became ambulance officers, they - we had 28 masseuses, people who give massage, also in the Australian Army Nursing Service.
On top of that, the military required some administrative roles to be fulfilled, such as being the duty sister in a ward, the home service sister in the hospital, and the home service sister was responsible for all the accommodation and feeding of the nurses, and when you consider that some of the hospitals may have had 100 nurses, that was no mean feat to carry out that role in a foreign country where English was not the primary language.
So there were lots of ways that nurses used their skills, particularly their management skills, because management was a key skill of nurses' training back in those days.
Ellen: A lot of the things you mention there are things that doctors would typically do in a hospital. Where were all the doctors at this time?
Dr Harris: During the war, of course, the need for doctors grew exponentially, and many doctors, of course, were included in the regimental staff of the people that were fighting at the front, and so doctors were killed. As doctors were killed and there were more and more patients, particularly from wounded patients and from patients with illness, then the demand for doctors grew across the world.
So many doctors were called into service who were quite young and straight out of university, and others who were, perhaps, elderly country doctors or even retired, who weren't familiar with modern hospital practices, perhaps had never seen an x-ray machine. So trained professional nurses, who were very up with all the medical techniques, were obvious choices to replace those people.
Ellen: Were there any female doctors at the time?
Dr Harris: Australia did have a number of female doctors that went to war, but none of them were employed in the Australian Imperial Force, in the AIF, or within the Australian Army Nursing Service. The director of medical services in Australia said he didn't want female doctors, so our female doctors who wanted to serve went overseas and served with the British forces or with other organisations.
In fact, some female doctors started their own hospitals where they employed only other female doctors. I think the feeling at the time was they wanted female doctors to stay back in Australia and look after people in Australia while the male doctors went overseas to the war.
Ellen: Dr Kirsty Harris from the University of Melbourne speaking there about the impact of nurses in World War I. Don't forget, if you'd like to find out more about anything you heard today, you can visit us at 2SER.com/.thinkhealth. You can also tweet us at 2SER. Please remember that journalists are not doctors. If we've made you ask questions, go and see your GP.
This show is produced with the support of the University of Technology Sydney Faculty of Health. I'm Ellen Leabeater. See you next week for more.
END OF TRANSCRIPT
