This study examined 861 valid responses to a 2022 Australian national survey which asked women and birthing people about their experiences of fetal monitoring during labour. We examined if there were differences in experience according to monitoring types, parity, hospital type, type of pain management utilised, and perception of benefit or harm for themselves and their babies. We found that place of birth was significantly associated with type of monitoring received, and that there were significant differences in women’s experiences of labour, and their use of pain management, depending on type of monitoring used. The perceived impact of monitoring as positive or negative was significantly different between monitoring types, especially when women received wired monitoring. This study has substantial implications for hospital resources and guidelines pertaining to fetal monitoring, as well as implementation of practices that support woman-centred models of care.
Type of monitoring used
We found that wired CTG monitoring was the most common form of monitoring with 35% of respondents overall, and 40% of primiparous women, stating this was their primary form of monitoring. This was consistent across most places of birth, except private hospitals in metropolitan areas, where over 60% of all women, and 67% of primiparous women experienced wired CTG monitoring. Wired CTG monitoring is ubiquitous in Australian hospitals (6), which is also reflected in our survey. Despite widespread use of continuous CTG monitoring, the use of telemetry – a wireless form of continuous monitoring designed to enable greater freedom of movement, remains limited (6). Despite wireless monitoring technology having been available for decades, many hospitals still do not have this routinely available, hence wired CTG monitoring still predominates in many settings (6, 8).
Barriers to use of wireless monitoring
In this survey, the next most common type of monitoring was ‘multiple’ forms of monitoring, which usually included failure of wireless CTG and progression to fetal scalp electrodes and/or wired CTG monitoring. When we examined why multiple forms occurred using text responses, it was mainly due to inadequate preparation of wireless devices (e.g. battery ran out), equipment failure, or failure to maintain an adequate fetal heart rate trace. This may be indicative of hospital resources, such as staffing, time required for management of intermittent handheld monitoring or the wireless equipment itself. This is suggested by a survey of nurses and midwives in a USA hospital, and by recent Australian research, where hospital staff report large portions of time on duty could be taken up ‘fiddling’ with wireless devices (13, 14), which is combined with limited availability of wireless devices available across all hospital types for women to use (6). Their survey also indicated that hospital managers reported that devices tended to be reserved for women who indicated that they planned to be mobile in labour and not have an epidural, requiring women to initiate and manage their labour plans and monitoring in advance, rather than an embedded culture of supporting physiology for all women.
In other quantitative results from this study, which are reported in a separate paper (reference to be added), 70% of women who experienced wired CTG indicated that they would not choose wired CTG monitoring again. Even women who experienced wireless CTG/telemetry monitoring were more likely to say they either would not choose it again or were unsure if they would. In our study, almost no women had non-invasive adhesive monitoring (NIFECG), and intermittent handheld monitoring was mostly used only in birth centres and homebirth settings. Just under 50% of both multiparous and primiparous women experienced handheld monitoring in birth centres and 95% experienced it in homebirth settings. Qualitative results from this survey study support this, showing that women found restriction of their movement in labour caused by the use of wired CTG was problematic for their sense of choice and control (10).
Resource availability and workplace culture
Resource availability is central to routine provision of telemetry and handheld monitoring. The cost of the equipment may be a factor for many hospitals, however, for private hospitals, where we saw the highest rates of wired CTG monitoring and where more resources may be available, investment in woman-centred approaches to birth should be prioritised. However, issues with staffing levels and time availability, has been suggested by Australian research (14), and USA based research (13) as a major barrier to providing woman-centred care. Financial investment includes providing telemetry monitoring, or newer non-invasive fetal ECG monitoring and prioritising having it available for each room. However, equipment alone is unlikely to improve women’s experiences. Staffing ratios and woman-centred models of care along with support for physiological birth practises also need to be prioritised. The promotion of physiological birth and woman-centred models of care have repeatedly demonstrated significant benefits for women, midwives and hospitals (2, 14, 15), including reduction in costs for hospitals and government (16–21).
Workplace culture has also been implicated in a mixed methods study conducted by Watson et al., in 2022 in the UK study regarding type of monitoring used. The study suggests that birth centres and continuity models of care offered wireless and intermittent monitoring as routine, with midwives suggesting its use is ‘embedded’ in the workplace culture. Women tended to be more upright and mobile in labour and more likely to birth in upright and/or forward positions (8). However more obstetric led models of care had an increased reliance on wired CTG monitoring, and greater likelihood of birth in recumbent or lithotomy positions. The study described midwives’ challenges in using wireless CTG monitoring, due to time required as well as training and experience. They also described their difficulty in supporting physiological labour and birth in units that were busy and catered to complex pregnancies, often reporting that they did not think to offer wireless CTG monitoring to women (8).
Resource implications are greater than the mere provision of monitoring devices, and extends to investment in research and development of well designed, less invasive wireless monitoring devices, as well as ongoing training for midwives and obstetric staff in the use of handheld monitoring. Perhaps the most important investment however, is in expanding woman-centred continuity of midwifery care models and training for midwives, so that care providers are able to promote physiological birth practices by having the capacity to spend time in “being with woman and not with machine”, as suggested by Fox and colleagues (14).
Autonomy and freedom of movement in labour
It is essential to consider women’s capacity for autonomy and bodily freedom when investigating fetal heart rate monitoring in labour. In this study, women who experienced wired CTG monitoring were more likely to use pharmacological pain management such as an epidural, nitrous oxide gas and opioids, and were the least likely to report using ‘supportive care’ techniques for pain management. Women who used telemetry and handheld monitoring were more likely to use non-pharmacological techniques such as movement, breathing, massage, acupressure and supportive care from partners or care providers. This is a unique finding from this study, showing the relationship of type of monitoring and women’s use of pain management strategies, which are clearly impacted. Women’s capacity to use supportive care and non-pharmacological techniques, assisted by freedom of movement, appears to be directly related to type of monitoring in this study. This finding supports the literature on women’s, partners’ and midwives’ satisfaction with use of non-pharmacological pain management in labour and the impact of monitoring on freedom of movement and bodily autonomy (7, 10, 14, 22).
In this study, primiparous women, were more likely to receive wired CTG monitoring, and less likely to give birth in free standing birth centres or to have a home birth. National reporting data indicate that primiparous women are increasingly more likely to have medical interventions, including induction of labour, with no medical indication, and to experience augmentation in labour (3). These women need to be given support with continuity models of care that are low intervention and favour intermittent handheld monitoring to utilise physiological practices to support normal birth. Australian women report wanting greater access to continuity models of care (23), which may lead to greater supportive care, less invasive forms of fetal heart rate monitoring and increased likelihood of normal physiological birth in the index pregnancy, leading to increased rates of normal births in subsequent births.
The implications of induction and augmentation of labour
According to the most recent Australian Mothers and Babies report (AIHW, 2023), over 35% of labours are induced, which is an indication for continuous fetal monitoring in most guidelines (1, 2, 24–26). Only 41% of women in Australia overall commence labour spontaneously, and of these 28% will experience augmentation of labour, which is also indication for continuous fetal monitoring, and is more likely among primiparous women (3). In previous research, women were asked retrospectively what they would have liked to have known before their first childbirth (27, 28). Most commonly women cited the process involved in induction of labour, in particular the monitoring required, which was felt to have not been adequately explained to them. This is an important consideration, as rates of intervention are increasing rapidly over time (AIHW, 2023). Where women experience wired monitoring, they reported being restricted in their freedom of movement in labour, use of water for pain management and other non-pharmacological support, which requires upright and mobile positions to support physiological birth as has been reported in the literature (6, 29).
Information about monitoring for women
Information about monitoring should be explained fully, on multiple occasions and early, so that women are able to gain an in-depth understanding of the risks and benefits of fetal monitoring and give informed consent. According to the NICE guidelines, women should have fetal monitoring options discussed with them by all care providers, including antenatal visits and education, which describes the risks and benefits in an evidence-based framework (30). This is supported by state and national guidelines in Australia (2, 24, 25, 31–34). Women in this study who had a normal vaginal birth were more likely to have experienced handheld or wireless monitoring or fetal scalp electrode monitoring, and women who had a caesarean section or instrumental vaginal birth were more likely to have had wired monitoring, and more likely to have used epidural analgesia for pain management. Even when we controlled for epidural use, women who had wired CTG monitoring were still more likely to have a caesarean section. While we cannot state a causative effect, or the direction of relationship, it is clear from the literature (6, 10, 29), and from results of this study that the relationship of lack of freedom of movement has an impact of women’s experience of pain, and their agency to manage their pain with non-pharmacological techniques.
Collectively, these findings suggest that the burden remains on women to understand the impact of monitoring and to have planned for, and articulated their wishes prior to birth. This suggests that routine care is often not woman-centred or embedded in a culture of encouragement and support for handheld, or wireless monitoring, especially for primiparous women. Women in our study, and are also examined in the qualitative results (10), as well as in the qualitative studies by Coddington et al., (35) and Watson, (8) report being ‘tethered’ or ‘strapped down’ to the bed when using wired CTG monitoring, which is deeply concerning. A recent survey of Australian women by Keedle et al., (2022), reported that more than 50% of women felt traumatised by their birth experience (36).
Perception of benefits and harms
Finally, when we asked women about their perception of whether monitoring had a beneficial or negative impact on themselves or their babies, women who had wired CTG monitoring indicated that they felt there was no beneficial effect of monitoring for themselves, and that it had a negative impact on their labour. However, while women overall neither agreed nor disagreed about benefit for their baby, they did not think it had a negative impact. The current narrative of birth in Australia and many countries internationally, is one of women’s sacrifice of bodily autonomy and freedom for the perceived benefit of the baby (37). Wired CTG monitoring is associated with increased interventions, less satisfaction for women and midwives, and reduced perceived comfort and benefit for women. This approach to increasing interventions is one that requires re-orientation of women’s position, if we are to achieve a humanised approach to birth (37), with the embodiment of philosophical approaches by midwives leading the change to supportive humanised approaches to childbirth for all women (38).
Strengths and limitations
This national survey examined valid responses from 861 women from all states and territories in Australia. A limiting feature of survey research however, is that the population was more likely to represent women who had higher education and income levels. Women in our survey were two years older than the national average of 31.1 years, and more were born in Australia than the average of 65.6% (AIHW 2023). There was lower representation of childbearing women who identify as Aboriginal and Torres Strait Islander (3.3%) compared to the Australian average of 5.1%, and there was lower representation from women in metropolitan areas than the average of 73.9% according to the AIHW Mothers and Babies Report (3). This may have influenced findings which are less representative of this population of women, in particular women from culturally, ethnically and linguistically diverse (CEALD) backgrounds or Aboriginal and Torres Strait Islander women, who are known to experience discrimination and lack of cultural safety in mainstream maternity care settings (39–41). However, research into the experiences of these women is a priority area (42) (43). Future research could explore priority groups’ experiences of labour, in language, and the use of fetal monitoring technologies to capture the views of more diverse populations.