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Military Midwifery

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Written by Liz McNeill, RM, RN, ADM

The images used throughout and in association with this article are the property of Rebecca Olsen Photography and have been used with permission from the artist.  

Where this all started...

My Army Reserve career started in Army Intelligence (yes, we joked about it being an oxymoron as well) and ended eight years later in the Royal Australian Army Medical Corps. My service was during the long peace, that is the period between the Vietnam war and Iraq 1. Since Iraq 1, we have sent Australian Defence Force (ADF) personnel, full-time and reservists, to several military campaigns, peacekeeping and humanitarian relief situations. During this time our medical teams, nursing officers and medics have had increasing interactions with civilians and pregnant women. Whilst nursing officers have been in the defence force unofficially since the Crimean War (more details below), we did not and still do not have any official designated midwives within the ADF. This blog outlines a brief history of nursing and midwifery in the ADF before introducing the broader concept of Military Midwifery.

Women in Defence

Women have served in or along-side conflicts for centuries. During the Crimean War (1853 to 1856) formal military nursing was revolutionised and bought to the fore by Florence Nightingale and Mary Seacole, although Florence is generally more known. In 1897, the Army Nursing Service Reserve was established due to Queen Victoria’s daughter Princess Halina, better-known as Princess Christian, being its champion, which meant at the time of the Boer War there were almost 2000 nurses employed.

In Australia, the New South Wales Army Nursing Service Reserve commenced in 1898 with nurses working during the South Africa Boer War (1900) in stationary hospitals and hospital ships (Chamberlain ND). Australia became a federated nation on Jan 1st, 1901 and in 1902 the Australian Army Nursing Service was formed (Bridges 2005). Supplemental to these early Army women were those women who funded private trips to areas of conflict or joined the Red Cross to help provide care not only to the troops, but also to civilians. The fortitude of these amazing women created the status and respect that our defence nursing officers have held ever since.

Current participation rates of females in the Australian Defence Force (ADF) overall in 2016 - 2017 was 16.5% with June 2017 participation rates for women being 20.4% - Navy, 13.2% - Army and 20.6% - Air Force (DoD 2017). ADF proposed 2023 participation rates are listed as 25% for the Navy and Air Force and 15% for the Army (DoD 2017). Therefore, the changing landscape of potential future military needs includes more female dominated combatants and the need for increased female ADF personnel to gather intelligence and community interactions in areas culturally inaccessible for males (Boulton 2017). 

Maternity care in Defence

Deployed ADF (Army, Navy and Airforce) nursing officers have looked after civilian women who have called on them for assistance during their pregnancies or when birth was imminent. Fast forward to 2018 and our nursing officers are working in both areas of conflict and in humanitarian disaster relief, which sees them increasingly in contact with civilian populations.  Several of the current serving ADF nursing officers are dual qualified, however their defence employment designation does not formerly recognise their midwifery qualifications (Stewart 2017). Historically, registered nurse training included an obstetric or maternity component.  However, contemporary registered nurse education in Australia does not generally include an obstetric component. Therefore, soon the ADF are at risk of having a nursing workforce without midwifery expertise.

Military Midwifery is a multifaceted concept, including:

  • currently serving nursing officers with midwifery qualifications;
  • midwives who are ex-defence themselves;
  • midwives whose partners are current serving or ex-defence;
  • midwives who care for women whose partners are either currently serving or ex-defence;
  • midwives who care for current or ex-defence women during pregnancy and childbirth;
  • pregnant defence women and their partners.

Midwifery aims to be woman-centred, caring for pregnant woman, partners and families as well. Some people do not identify on the binary gender classifications and there are male and female partners. Whilst the terms woman and partner are used in this blog, they are not intended to be exclusionary.

Experiencing Maternity care in Defence

The experiences within the cohort of military midwifery can be wide ranging. In preparation for writing this blog I spoke to several female veterans (serving and ex-serving) to ask them what they considered relevant midwifery issues in the military. These conversations reinforced personal anecdotal stories and had common themes.

These are some of the issues that have been mentioned in general conversations with current and ex-serving defence women related to midwifery.

Not women-centred /lack of choice

Military midwifery has lacked a woman-centred structure and organisation. Several women spoke about the lack of choice around the model of care that they were able to use during their pregnancy. For example, when women were confirmed pregnant, the Department of Defence (DoD) provided them the details of a local obstetrician (with no other options provided or considered).

Restrictive policies

Montalban (2017) provided a critical analysis of the ADF policy on maternal health care, finding that existing ADF policy restricted women’s choices and contributed to health inequalities.  There have been several internationally published reviews on the advantages of midwifery led continuity of care for low risk women including the 2016 Cochrane review (Sandall et al 2016). Last year RANZCOG (2017) also released a new guideline for maternity care in Australia. In a positive step towards evidence-based care, the ADF has recently changed policies in line with RANZCOG.  The new policy includes a wider range of approved evidence-based models of care (Stewart 2018) although there is still room for further expansion.

Increased costs & interventions

Medical and dental care within the ADF is ‘free’ for full-time serving personnel however, without prior arranged private health insurance, pregnancy may become costly. Service women have felt that the DoD recognised pregnancy as an illness to be managed by doctor and did not encourage midwifery antenatal care.

Whilst ADF women are generally low risk during their pregnancies and birth, several spoke about the higher medical interventions and increased financial burden because of being required to follow the private model of care.  The private model of care often left women confused and without options in the post-partum period. The costs for a baby admitted to a special care nursery soon mounts in the private hospital whereas it would be covered through Medicare in a public hospital.

One defence woman stated that she consulted with five different obstetricians before she found one she was comfortable with and who had participated in a recent ‘normal’ birth.

Support networks

A significant issue for Military Midwifery is a lack of a support network due to regular postings every few years. Such frequent relocations not only interrupts continuity of health care but also social networks. Within the civilian community, couples who go to antenatal and breastfeeding classes can meet other couples and start to form their own support groups. This generally has not occurred within defence but with the recent expansion of models of care, hopefully this will change. Whilst technology has helped to breach this gap in some cases, with Skype, FaceTime and other social media style applications enabling distance partners to witness births or connection with other mothers, more lateral thinking is needed to further utilise these alternative methods.

Deployment

There is also a recognised ‘traditional roles’ culture in the ADF. Women spoke about how men can be deployed without apparent consequences, yet their female partners are automatically expected to look after the children, regardless of whether she is a serving member herself. Women have left the service due to the increasing probability of both parents being deployed at the same time. This also extends to females being the first parent contacted if children are ill, even when the partner is non-serving and more available.

Barriers to accessing maternity leave / reduced breastfeeding rates

The ADF has a 12-month maternity leave policy (up to 14 weeks paid: DoD 2018) with 4% of women accessing paid maternity leave in 2011 (AHRC 2012).  Several women that I have spoken to stated that they were either actively deployed or required to attend promotion courses 3 – 6 months post-partum. This resulted in them all ceasing breastfeeding early and requiring the grandparents to look after their babies as both parents were deployed. These separations also present a variety of psychological and attachment issues upon return which is starting to be explored regarding long term effects.  

Postnatal fitness

Postnatal physical issues include regaining the required levels of physical fitness and maintaining breastfeeding or pumping were deemed major issues by several women. None of these women argued the need to be at the required physical fitness levels for their designation role.  However, what they commented on was the lack of support and understanding of the physiological changes a woman’s body goes through following pregnancy and birth.

Sexual assault / PTSD

Unfortunately, too many serving and ex-serving women have experienced sexual assault and Post Traumatic Stress (PTS). I have been told stories of servicewomen who have been sexually assaulted during their service and how they were in the active stage of pushing, their mind was having flashbacks and re-living the assault/s. Considerations are also needed when dealing with ADF members (women and their partners) who have PTS and how they deal with their triggers as well as in some cases, physically being in hospitals. It can be easy to be judgemental towards people’s behaviours if we do not know the background.

Midwives do not always need to know the events that have caused the partner PTS however, insight in the pregnant woman’s causes e.g. sexual assault, can help in advocating and supporting at all stages of the therapeutic relationship. Familiarity and continuity of care can aid in women sharing their experiences and enable them to work on strategies ahead of time.

Orders

Obeying orders is fundamental in the ADF. Women have stated that many servicewomen have taken on a more submissive role during pregnancy and birthing due to the military conditioning of following order. Consequently, they have not had the birth that they wanted because they were not used to advocating for themselves. This may be a critical role for midwives when working with women connected to the ADF and would be strengthen by continuity of care.

Where to now…

New ADF recruits are generally fit, healthy young people therefore as there is a push for more females, there will also be in need for increasing military midwifery considerations.

There is some exciting research happening because of personal experiences by defence women that will shed more light onto some of these areas.  Other research areas have focussed on pre-pregnancy issues e.g. Lawrence-Wood et al (2016) explored the literature into the effects of active military service on sexual and reproductive health in serving and ex-serving women. More research is needed in the future to ensure that ADF policies are evidence-based.

As a consequence of preparing for this blog, a new supportive community called Military Midwifery can be found in the Facebook group, (https://www.facebook.com/groups/284735305612682/ ), on LinkedIn ( https://www.linkedin.com/groups/13608964 ) and on Twitter (https://twitter.com/MilitaryMid). If you would like to continue the conversation, please feel free to join us.

 

References

Australian Human Rights Commission (2012) Review into the Treatment of Women in the Australian Defence Force, Phase 2 Report  https://defencereview.humanrights.gov.au/sites/default/files/chapter6.doc

Bridges D (2005) “The Gendered Battlefield” Women in the Australian Defence Force, Thesis University of Western Sydney, https://researchdirect.westernsydney.edu.au/islandora/object/uws:471/datastream/PDF/view

Chamberlain M (ND) Nurses in the Boer War, Royal Australian Armoured Corps Association NSW https://www.bwm.org.au/nurses.php

DoD – Department of Defence (2017) Women in the ADF Report 2016-2017 http://www.defence.gov.au/annualreports/16-17/Downloads/WomenInTheADFReport2016-17.pdf

DoD – Department of Defence (2018) Division 2: Maternity leave entitlements http://www.defence.gov.au/PayAndConditions/ADF/Chapter-5/Part-6/Div-2.asp

Lawrence-Wood, Ellie; Kumar, S; Crompvoets, S; Fosh, BG; Rahmanian, H; Jones, L and Neuhaus, S. (2016) A systematic review of the impacts of active military service on sexual and reproductive health outcomes among servicewomen and female veterans of armed forces [online]. Journal of Military and Veterans Health, Vol. 24, No. 3, Jul: 34-55. Availability: <https://search.informit.com.au/documentSummary;dn=258754516088220;res=IELHEA> ISSN: 1835-1271. [cited 12 Aug 18].

Montalban, M. (2017). A critical analysis of the Australian Defence Force policy on maternal health care. Australian and New Zealand journal of public health, 41(4), 399-404.

RANZCOG 2017, Maternity Care in Australia - https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/About/Maternity-Care-in-Australia-Web.pdf

Sandall J, Soltani H, Gates S, Shennan A, Devane D. (2016) Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub5

Stewart K, (2017) Having a baby in the ADF -Where’s the Midwife?, Australian Midwifery News, Autumn pp 38-39

Stewart K, (2018) Update to Having a baby in the ADF -Where’s the Midwife?, Australian Midwifery News, Autumn pp 36-38