Critical analysis of articles published in 'The Age' generated a number of discourses exerting influence on general public opinion. By far the majority of articles were concerned with sensationalising the deficiencies of maternity services. The articles featured attention grabbing headings, highlighting issues pertaining to the state of maternity services, supplemented by a range of expert opinions including the relevant government authority, medical or obstetric experts, Australian College of Midwives (ACM) and consumer groups.
Expert consumer opinion was sought by 'The Age' from organisations such as maternity coalition or future families, advocates for primary maternity care reform supporting natural birth options. These organisations are well organised publicity machines promoting their position on natural childbirth . What was found to be missing from the perspective of the newspaper was a similar organisation representing the position of women satisfied with obstetric care. To address this deficit 'The Age' newspaper undertook a survey of women who had given birth in the past five years through the Fairfax essential baby website, attracting 2,792 participants who were asked specific questions regarding their experience of maternity care.
The state of the maternity services
In the process of sensationalising the deficiencies of maternity services, a number of articles extensively reported on the findings of a survey of 2792 mothers highlighting the traumatic or unsatisfactory experiences of women giving birth. Discourses generated from a critical analysis of that study included; 'the interests of women and their babies must be the focus of maternity care, not the system and those who work in it', 'next please, feeling depersonalised in the queue'. These discourses imply that current maternity services operate in the interests of the institution and maternity care professions and not in the interests of the women receiving care. The woman's personal experience and special needs are dismissed in an overstretched system providing a 'one size fits all service'. Selected statements illustrating the meanings of these discourses included:
'Women feeling like cattle being pushed through herding yards that put both their own and their babies' lives at risk. Hundreds of women felt that both public and private maternity wards are overcrowded, needed more midwives, performed too many unnecessary medical interventions and did not provide enough non-drug options for pain relief (quote article 18).
'Nothing could have prepared me for my horrible birth experience - "herding yards does not go nearly far enough in describing the way the hospital treats new mothers and babies (quote article 14).
The safety of overcrowded and understaffed metropolitan maternity services is called into question in the majority of these news articles. It has been argued that maternity care in Australia is delivered in an outmoded 'hospital nursing' model  that has been proven over the years to be inflexible in meeting the complex psychosocial and emotional needs of women having babies [27, 28]. Constraints associated with running a hospital contribute to the provision of fragmented maternity care to women who need the support of continuity of care at this important time in their lives [25, 29]. Conflicting information and advice is a feature of current maternity services with staffing arrangements that cannot secure a known caregiver. A constant stream of unknown carers undermines trust women have in the care received and decisions being made. Discourses generated from this study include; 'women feeling vulnerable in the care of a parade of strangers', 'women expected to place blind trust in those who know nothing about me and still feel safe'. Selected statements illustrating the meanings of these discourses included:
'A large public hospital means a huge variation in staff on different shifts, which leads to inconsistent care and the danger of falling through the cracks' (quote article 17).
'The most concerning theme centres on the apparent shortage of resources in public hospitals, leaving many women feeling as if they and their infants are being exposed to unacceptable risk' (quote articles 18 & 21).
'Because of workforce difficulties, care is fragmented. Women might see 12 or 13 diffent people during the pregnancy' (quote article 27).
A number of the newspaper articles reported on the findings of the national review of maternity services released in 2009. One of the main messages highlighted in the articles is the need to respect women's right to choose, inferring that women are not being offered choice in the maternity care they receive. Some women in an attempt to investigate childbirth options find themselves labelled by the health professionals, on whom they rely, as being 'difficult' or 'untrusting' . Discourses generated from this study include; 'maternity care options need to be expanded to allow women choice in the care they receive', 'the demonization of women who choose to give birth naturally'. Selected statements illustrating the meanings of these discourses included:
'Stop treating pregnancy as an illness and respect women's birth choices' (quote article 35).
'Women seduced by the "empowering" idea that only a woman knows how to deliver her child forget that 100 years ago 1 in 10 women died from complications of childbirth and 1 in 10' (quote article 25).
'Women do not have to prove to health professionals that their healthcare choices are good or worthy ones to have the right to decide' (quote article 1).
Several newspaper articles question why Australian women are more anxious about their pregnancies despite Australia's safe record in childbirth. The chance of a women dying during childbirth in Australia is remote . Of concern is when high levels of fear are sustained due to women's perception of their own birth risk being out of proportion to actual medical risk [7, 30]. Everyone wants a healthy child and women willingly do whatever they have been led to believe might help . Discourses generated from this study include; 'every pregnancy is treated with suspicion until proven otherwise', 'modern medicine knows best and women are best served to listen to the experts'. Selected statements illustrating the meanings of these discourses included:
'Many women are feeling more, rather than less, anxious about the birth process. Some blame this on our risk-averse society, saying the screens and tests and the increasing level of intervention in birth and pregnancy is geared towards making women fearful. Antenatal care has become antenatal scare' (quote article 7).
'The woman's surgery was scheduled without her consent and she claimed she was bullied by hospital staff, who said her baby could die if she did not follow their advice. This new mother never wanted to birth at home - she wanted the support of the hospital but the system would not provide the care' (quote article 30).
'In one Australian study, 62% of women who had a caesarean section in a private hospital said their health care provider had recommended it' (quote article 1).
'There should be more continuity of care. Knowing your carer and trusting your carer removes the fear from childbirth and fear leads to more interventions' (quote article 19).
In the rural setting
The plight of rural maternity services was highlighted in a number of articles as a serious deficiency in current maternity service delivery , a situation exacerbated by continuing service closures . The inequity experienced by pregnant women living in rural and remote locations forced to travel long distances to access maternity care, is raised as a failure of government to provide essential services to these communities [31–33] placing lives at risk. The deadly consequences associated with insufficient rural maternity services was highlighted by the report of the death of a pregnant Victorian woman. Rural services were compared to third world conditions reinforcing an inequity imbedded in a system that privileges one group over another, usually the more vulnerable group. The discourse identified; 'the lives of mothers and babies in rural communities are placed at risk by widespread closures of maternity services'. Selected statements illustrating the meanings of these discourses included:
'Since 1996, 40 maternity units had closed across the state and others were near closure. It's reflective of a general shortage of GP's across rural Australia. As a society we have not invested enough in GP proceduralists: doctors who provide obstetric care, anaesthetics or emergency' (quote article 26).
'Urgent action is required to prevent women enduring "roadside births" as they travel hundreds of kilometres to dwindling maternity services in regional and rural Australia' (quote article 34).
'Reopen my local maternity unit. Travelling while in labour is not only uncomfortable, but dangerous. (we only just made it to the hospital before our baby was born' (quote article 19).
Expert opinion on controversial issues
All articles retrieved for this study presented a range of expert opinion on the topic featured, usually including the relevant government authority, medical or obstetric experts, the ACM and consumer groups. Opinions represented a range of views often involving polarised positions on the issue. Consumers and midwives reinforced the position of natural birth and challenged increasing rates of medical intervention. Medicine or obstetrics highlighted the dangers of medically unassisted childbirth while the government defended the proposed maternity service policy direction. The main issue debated in the articles centred on contention surrounding government support for midwifery -led maternity services extending to including controversial home birth trials. As exemplified in the statement:
'Victorian women will be able to give birth at home - with hospital back up for the first time - under a pilot project starting at three hospitals next year' (quote article 22).
The safety record of home birth is reported in a number of newspaper articles as having received a boost with several large studies in recent years reporting no significant difference between planned hospital birth and planned home births, as long as the mothers have access to trained midwives [34, 35].
'A Dutch study of more than 500,000 women reported that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low risk women provided they were supported by well trained midwives and a good transportation and referral system' (quote article 24).
Medical or obstetric opinion reported in the newspaper articles reflect the position that they are the guardians of safety in childbirth in the belief that only they have the training and expertise for safe birth outcomes to be achieved . The expert voice in this regard is the president of the Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) who reminds readers that current excellent obstetric outcomes are due to high quality medically- led maternity services . A position supported by the secretary general of the Australian Medical Association (AMA) warning that the introduction of non-medically led services will undermine the quality of maternity services in Australia and threaten the safety of mothers and babies . Discourse generated in this study; 'childbirth is unsafe in the absence of medical expertise', 'a healthy baby is all that matters'. Selected statements illustrating the meanings of these discourses included:
'Of course, women might feel that sometimes the medical profession interferes too much in what is a natural process, but the reality is that if left to mother nature then the outcomes is not very good often. There needs to be a sensible balance struck between interfering in a natural process but judiciously intervening when things start to go wrong, or preferable before things start to go wrong' (quote article 7).
'The trouble is we take safety for granted now and are arguing about quality issues, like maternal satisfaction, which is important. But I'm sorry not as, as a clinician, survival is the most important thing' (quote article 25).
'If birth is a natural process so is getting cancer and dying' (quote article 12).
'It's a myth to say that the most important thing is a healthy baby. Traumatic birth gets carried with you - you don't leave it at the hospital- and it can have the most profound consequences for both the mother and baby' (quote article 7).
On the issue of expanding midwifery -led maternity services as part of the proposed primary maternity care reform agenda some medical and obstetric opinion reported in new articles became divergent as seen in the following statements:
'I fear the introduction of a system where women are pressured into having a natural birth that puts them and their baby at risk' (quote article 18).
'If we can have a patient seeing either the midwife or the GP depending on who is the appropriate person at the time, then that's going to benefit the patients and free the GP's up to be able to see other people. The GP's in rural area's providing birthing services know they can't do it by themselves' (quote article 23.1)
On the issue of planned home birth there is strong resistance reported in news articles from medical experts a position supported in a recently published systematic review of the medical literature on the maternal and newborn safety . Findings are consistent with earlier reports that planned home birth is associated with a tripling of the neonatal mortality rate. The newspaper report failed to clarify whether results included planned home births with experienced midwives in attendance or the controversial practice of free birth in the absence of any professional assistance.
'Any birth at home under the care of midwives was unsafe and should not be supported by governments (quote article 2).
A source of confusion for the general public is evident in reports of obstetric opinion where midwifery services are only recognised as they relate to home birth, failing to acknowledge the work of midwives across the full range of maternity services. Discourse generated in this study; 'midwives act irresponsibly when attending a women birthing at home', 'home birth is a return to times past where mothers and babies died in vast numbers'. Selected statements illustrating the meanings of these discourses included:
'Midwives do things in a home setting, that no maternity service around the developed world would think a good idea' (quote article 36).
'Home births with or without midwife help, increase the risk of infant death three fold' (quote article 27).
The opinions of consumers are varied. Consumers advocating for increasing services supporting natural birth project positivity around women's ability to give birth with minimum intervention in a safe environment. The consumers represented in 'The Age' survey appear fearful, unsure of what is best, placing their trust in health professionals to keep them safe. There is evidence to indicate the presence of the 'what is must be best' belief where the public values the status quo over options for which they have little experience [40, 41].
Contrasting discourse were generated in this study; ''women are the experts in giving birth, trust our bodies to keep us safe', 'Australia is one of the safest countries in which to give birth or be born, what is must be best'. Selected statements illustrating the meanings of these discourses included:
'While most mothers were generally satisfied with their experience of the maternity system, hundreds of women felt that both public and private maternity wards are overcrowded, needed more midwives, performed too many unnecessary medical interventions and did not provide enough non-drug options for pain relief' (quote article 18)
'A lack of obstetricians available after hours means junior registrars are making critical decisions, often bad ones'. I was not supported well enough to have a vaginal birth. I felt like they were more concerned with getting me in and out quickly so they could free up the beds (quote article 19).
Consumer opinion reported in newspaper articles on the issue of midwifery -led maternity services including home birth was sought from consumer organisations advocating for non obstetric -led services, supporting women to give birth safely with minimal intervention . Consumer satisfaction with these services was described in glowing terms. Discourses generated in this study include; 'women need to be able to trust their caregivers to act in their best interests, not in the interests of the hospital, doctors or midwives' and 'safe and secure in a relationship built on mutual trust and respect with a known carer', represent the differences in experience between a fragmented maternity service and what can be achieved in a caseload continuity of care or home birth model.
'Over 400 submissions to the national review from consumers, the majority requesting greater access to home birth cannot be ignored any longer' (quote article 24).
'You seem to have left out the home birth option in your report. Provided the women is healthy, well informed and well supported, there is no reason she cannot give birth at home with the aid of a trusted midwife. My wife did so three times, 25 - 30 years ago (quote article 17).
While most of the news articles are concerned with the exciting process of giving birth, consumer opinion raises the issue of private and public hospital care following birth. Traumatic experiences of new mothers left to care for their babies following caesarean surgery are described, as are distressing stories describing lack of support with breast feeding. Discourse generated in this study; 'recovering from the effects of surgery while struggling to mother my baby'. Selected statements illustrating the meanings of these discourses included:
'Thirty per cent of women in postnatal care wards have had major abdominal surgery and they are expected to try and care for a newborn baby' (quote article 9).
'Nurses are not caring for women after caesareans properly because of overcrowding. Unless you scream the loudest you don't get looked after' (quote article 19).
Expert opinion supplied by the ACM strenuously challenges the obstetric position that only they have the training and expertise to safely care for pregnant women. In each article the midwifery professional body challenges current obstetric practices leading to rising rates of medical intervention and culminating in an alarmingly high rate of caesarean section in healthy young women having their first baby. Discourse generated in this study; 'rates of medical intervention in Australia are too high', 'medical intervention is not without risk it comes with the potential for serious complications'. Selected statements illustrating the meanings of these discourses included:
'We (midwifery professor) have consistently found that 30% of women report that their birth was traumatic; that they feared for their life or their baby's life. This is a very high figure. We also know that about 6% go on to develop post-traumatic stress disorder' (quote article 7).
'Babies born by caesarean section are more vulnerable to asthma, allergies and infection because they miss out on receiving their mothers' good bacteria during birth. Babies delivered vaginally received protective bacteria as they pass through the birth canal (quote article 8).
Reported midwifery opinion reinforced the desirability of midwifery -led maternity services designed to meet the needs of women as mothers. The ability to build a relationship with a known carer based on mutual respect and trust is promoted by advocates of midwives as the panacea for being able to control levels of fear, maintain feelings of being in control throughout the birthing process and being satisfied with the outcome of the experience .