A relational model of medical care for vulnerable pregnant women

10 MINUTE READ

From Luke’s Journal 2022 | Termination of Pregnancy | Vol.27 No.3

The Consultation

For a Christian healthcare professional, the consultation with a woman who finds herself unexpectedly pregnant is a unique and deeply challenging opportunity. It is one that many dread, with the fear of the Australian Health Practitioner Regulation Agency (AHPRA) hanging like the sword of Damocles and the pressure to conform to political and societal expectations a heavy presence in the room.

Some choose to avoid this situation completely, posting signs in the waiting room to deter any patient who may be considering such a conversation. Others accept the challenge awkwardly, not quite knowing where to look or what to say. They feel relief when the woman leaves the room, satisfied that they complied with the minimum referral standards while not compromising their own values or being complicit in any way to the decision the woman makes after leaving.  

In my years as a GP Obstetrician, it has become apparent that the reason this consultation is difficult is because referring a woman for termination of pregnancy is the ‘wide and easy road’ for a practitioner. The consultation would be much simpler, and our day would run to time if we merely gave her that referral and sent her on her way. But, as Christian doctors, we invariably have hesitations about this being the best choice. While termination may appear to be the easier option for us and for the woman, we know that this pathway of care often leads to harm.

“But, as Christian doctors, we invariably have hesitations about this being the best choice. While termination may appear to be the easier option for us and for the woman, we know that this pathway of care often leads to harm.”

Yet to sit with her and hear about the social isolation and lack of support, the unemployment, the domestic violence, the lack of safe housing – all the factors in her life that lead her to feel she has no choice in the matter – this is much harder. And whilst we may choose to sit in compassion and listen, cancelling or delaying the next hour of appointments to allow us the time to be thorough – actually finding solutions that make her load easier and give her hope feels practically impossible.

The Choice

The divisive debate around abortion – well known by the polarised placards of the pro-life and pro-choice movement – fills the echo-chambers of social media, the corridors of parliament and the sidewalks of city marches. The recent overturning of the Roe v Wade case in the USA has further fuelled the emotion and vitriol around this issue. But how does this rhetoric translate into care for the woman before you, with the world on her shoulders; not knowing what to do or where to turn?  Sure, she can go down the road and end the pregnancy, with a referral in hand, or not. Most women are acutely aware of that option. There are an increasing number of GPs who are authorised to prescribe MS2-step (mifepristone and misoprostol) medical terminations; and there is a centre in most regions that offer surgical solutions for women less than 16 weeks gestation. There is also an escalating push to widen this access, with public hospitals coming under pressure to offer terminations or risk their funding; telehealth abortion services expanding exponentially; and governments promising increased funding to remove financial barriers for women seeking terminations (the ACT Government recently announcing $4.6 million over 4 years to remove out-of-pocket costs for women accessing terminations <16 weeks gestation). 

Increasing cultural pressures, often aided by the lack of alternatives offered when help is sought, commonly lead a woman to believe that ending the pregnancy is the expected and best thing for her. But where does this leave her after she has gone through with it?  Society told her that ending the pregnancy was a triumph for women’s rights, a win for exercising her right to choose. Yet is it a ‘choice’ where there appear to be no other valid options? If she was alone prior to choosing the pills or procedure to end the pregnancy, she likely remains without anyone by her side. She may be bleeding heavily, with little follow up or post-termination care. She may still be without a safe place to live, without a job, or in the same violent relationship that led her to end the pregnancy in the first place.  Surely this is not the highest goal for which we should strive. Surely our women deserve better. How can a society possibly flourish if this is considered ‘progress’ and a glorious achievement to be celebrated? There must be a better way.

The Problem

We make the mistake of assuming that the underlying cause of a woman’s disadvantage is economic. And with the cost of living rising so steeply, one might be forgiven for this assumption. But it is not economics that lie at the core of homelessness, poverty, domestic violence, or social isolation. Rather, it is a lack of healthy relationships that is the primary factor in most instances. Healthy and strong family relationships correlate directly with access to practical support, resource provision, emotional care, respite, peace of mind, and a safe home. In contrast, where there is a lack of healthy relationships, women are far more likely to experience significant disadvantage. And for these women, an unexpected pregnancy can cause disadvantage to quickly become a crisis.

There are three potential outcomes when there are a lack of healthy relationships and support networks in a woman’s life. Firstly, the woman may end the pregnancy, not necessarily because she doesn’t want the child but more likely because she is overwhelmed, under-supported, and feels there is no other choice. Secondly, she may continue with the pregnancy, but ultimately have her child taken from her after birth because she does not have the right people in place to enable her to safely continue to care for the child. And finally, the woman may continue with the pregnancy and manage to keep her baby, but go on to live with the same risk factors she was enduring prior to having a child – only now she is at an even greater disadvantage due to the demands of being a mother.

The reality is that the health system as we know it cannot provide the relational community that is needed for these women.  I cannot possibly offer this kind of care in the twenty minutes I spend with a woman in my general practice rooms every few weeks.

The reality is that the health system as we know it cannot provide the relational community that is needed for these women. I cannot possibly offer this kind of care in the twenty minutes I spend with a woman in my general practice rooms every few weeks. Likewise, the hospital midwives and social workers cannot provide this support in their allocated time slots. Their appointments may help put out spot fires and facilitate some essential services for the woman, but they know better than most that this is simply not enough. There must be more that we can offer beyond confined appointments and narrow service provision. Women need community. They need relationship. Women need comprehensive and whole person care.

The Opportunity

One of the great mistakes of the current medical perspective is that pregnancy is fundamentally seen as an additional risk factor that needs to be mitigated.  Whatever the cause of a woman’s disadvantage, pregnancy is seen to increase it. If a woman is unemployed, she will have an even harder time securing work if she is pregnant. If she is in an abusive relationship, being pregnant will commonly make this worse. If she has depression or anxiety, her vulnerability to exacerbation of her conditions in the perinatal period will be a cause for significant concern.  The cost and sacrifices required to raise a child will be seen to greatly limit her opportunity for life-improvement into the future.

While there is some truth in these concerns, I have come to realise that pregnancy also has the potential to be a key transformative event in a woman’s life. Perhaps for the first time ever, she may actively seek care for herself, consider her future, and set her sights on building a strong foundation for her new family. This provides a tremendous opportunity for health practitioners involved in her care. We are privileged to play a part in countering the narrative of disadvantage and instead help the woman to find the support she needs to turn this around. This might include facilitating healthy peer and mentoring relationships, engaging in holistic care for her physical and mental health, and equipping her to become a capable and confident mother who can overcome the challenges she faces. If you help build a mother’s resilience, providing her the medical, social and relational support required for what can be an incredibly difficult time, then this decreases the risk factors that lead to disadvantage for her and her child’s developmental outcomes. If done well, this is the most powerful opportunity in her life to break the cycle of generational disadvantage that plagues our communities.

If done well, this is the most powerful opportunity in her life to break the cycle of generational disadvantage that plagues our communities.

Just this week I met a girl who is in her second trimester. She came to see me directly from work where she has a stable income. She has recently moved back in with her Mum which means she has a safe home to go back to after she finishes our appointment. The story she told me of her recent months did not match with the girl that sat in front of me. Only recently, she was homeless, unemployed, estranged from her family and in a dangerous cycle of alcohol addiction and drug use. She had an abortion a few years back which she identified as a key event that furthered her downward spiral. She had multiple suicide attempts and no hope for her future. When she found herself unexpectedly pregnant again, she knew she could not go down the same path as before. She knew she would not survive it.  Both the physical trauma and mental pain it put her through was not something she could repeat. Being pregnant has helped her to begin to turn her life around. She has “done a complete 180” as she explained it.  She still has a long way to go to overcome the obstacles she is facing, but being pregnant has given her a reason to live and she has started to make changes that will have a lasting impact on her future and that of her child. I feel honoured to be a part of that journey.

The Vision

First Steps Pregnancy Support (FSPS) began as a small group of passionate professional Christian women who got together to discuss how we could make a difference in our region for the many pregnant women experiencing disadvantage. We began by compiling a directory of all the local services available that have support to offer a pregnant or newly-parenting woman. This is now a fantastic resource for local service providers, but we soon realised it was only a small part of the solution to providing better pathways of care for these women.  We concluded that a central contact point was needed, within a relational context, to coordinate this care.  While there are many wonderful pregnancy support organisations that operate as social services, we as health professionals had a heart for providing the additional layer of evidence-based comprehensive medical care for pregnant women facing challenging circumstances.

We aim to create personal pathways of care with each woman to ensure she receives support that is tailored to her individual needs. The wider community has so much to offer, and we will facilitate her access to the service providers that already exist in the region as well as local businesses and professionals who are eager to lend a hand. Our medical expertise will enable us to provide evidence-based education and health advice throughout pregnancy and into parenting – an area that is majorly lacking in our current health system and leaves women feeling anxious and completely unprepared as they anticipate birth and motherhood. We aim to offer mental health support that is multi-faceted and may include mental health treatment plans, medication and referrals, in addition to counselling and general support. We aim to provide an alternative pathway where a confronting antenatal diagnosis is faced, to give time and space for a decision to be made, and to provide medical oversight through this process.  In addition, we hope that First Steps Pregnancy Support will give our local medical colleagues confidence to support women who are pregnant and in challenging circumstances throughout their pregnancy and post-natal care, because they recognise the opportunity for transformation and have a clear referral pathway to facilitate this journey in the context of relational care and community.

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A “First Steps Pregnancy Support” Scenario

Renee* thinks she is about 10 weeks pregnant.  She is referred to First Steps Pregnancy Support (FSPS) by her GP after an initial early pregnancy consultation. She is in a very difficult situation with an abusive partner, no family to support her and she recently lost her job as she was struggling to get out of bed in the morning. She was not meant to fall pregnant, and she cannot see a pathway ahead that could allow her to continue with the pregnancy even though a part of her thinks she might want to.

When she walks through our doors, she feels welcome with FSPS team members greeting her, giving her a cup of good coffee and spending time with her. She feels listened to by our available social worker who talks with her about her past, where she is at currently, and what her hopes are for the future. She feels hopeful for the first time in forever, as she hears about the wide range of support that is available to her within the local community.  She feels cautiously excited as she meets with one of our doctors and has the opportunity to see her baby for the first time on our ultrasound machine.  She feels reassured when she is told that she is in good health and she very much could continue with her pregnancy if she wanted to, with regular input from the First Steps team and help to link in with other services in the area. She leaves our clinic feeling valued as a person, optimistic for the future, and supported by our staff as well as the community networks with which we have offered to engage her.

This first visit is just the foundation for the care we will be able to offer this woman. As her pregnancy progresses, she is able to gain greater independence when a local business responds to our social media request and offers her casual employment.  She attends our birthing classes and preparation for parenting groups and grows in confidence as she prepares to be a mother. She attends our weekly drop-in sessions and finds friendship and acceptance amongst the other women that are pregnant or have recently had their babies. Through the local community network, she is able to find a place of safety after having the courage to leave her abusive partner.  She feels empowered through the support she is given by a local lawyer who helps her to navigate the system following her relationship breakdown.

And ultimately through all of this, she continues on to give birth to a healthy baby girl who becomes the centre of her world and with whom she develops an unbreakable bond. Her daughter goes on to grow up with a capable and self–assured mother who has found her place in the wider community and who can love her and provide for her, still within the context of a supportive community. She continues to attend weekly drop-in sessions at our clinic to support new women coming through and to share her experiences with them, giving her life experience further meaning and purpose.[1] 

*Renee is not a real person, but a constructed story based on combined anecdotal experiences.
Whilst First Steps Pregnancy Support is not yet in the operational phase, this is the vision we have for women who come through our doors.  We hope to begin taking clients in early 2023. For more information visit www.fsps.org.au or email contact@fsps.org.au.

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