The relationship between first-time mothers and care providers in the early postnatal phase: an ethnographic study in a Swiss postnatal unit

Objective

to consider the relationship between first-time mothers and care providers in an organisational context.

Design

an ethnographic approach was used to study the views and behaviours of providers and recipients of postnatal care. Fieldwork involved mainly conversations or qualitative interviews and observation.

Setting

a postnatal unit in a tertiary referral hospital in Switzerland.

Participants

10 child-bearing women and the care providers assigned to them.

Analysis

analysis of the data was organised using the women’s expectations of care and the maternity unit’s mission statement. Thematic analysis centred around two main themes: the experience of ‘being on a postnatal journey’ and ‘caring relationships’.

Findings

the findings presented fall within the framework of the second theme. A caring relationship was established through ‘weaving the net’. This relationship was then maintained through ‘keeping the thread’. The relationship was eventually ended through ‘finishing off’.

Key conclusions

the quality of the caring relationship between a woman and a care provider influences satisfaction with received care. It determines the extent to which women feel in control of their situation at discharge. Organisational and professional factors influence this relationship, which in turn can influence a nurse's level of job satisfaction.

Implications for practice

changes in the provision of postnatal care may involve organisational as well as clinical interventions to ensure continuous and consistent care.     

Mothers’ birth care experiences in a Brazilian birth centre

Objective

to explore the reasons why women with previous hospital experience seek care at a birth centre, and their perceptions related to the care received in both settings.

Design, setting and participants

in-depth interviews focusing on the care experiences of 18 women who received birth care in a birth centre of the Brazilian public health system.

Findings

three key themes emerged from the analysis: ‘Confrontation with strong problems in the hospital setting’, ‘Reasons to seek the birth centre’ and ‘Satisfaction related to birth centre care’. The main aspects that the mothers mentioned in the first and third themes were related to the institutional structure and system of care.

Key conclusions and implications for practice

mothers’ narratives suggested that their previous experience of problems in the hospital setting was the main motive for seeking care at the birth centre. The most important components of birth care were attention, meeting personal care demands and establishment of an adequate interpersonal relationship. More sensitive birthing care in the hospital setting is necessary, and this can be promoted through continuing professional education.     

Low postnatal care rates in two rural counties in Anhui Province, China: Perceptions of key stakeholders

Objective

to explore the perceptions of stakeholders on postnatal care and to describe the rate of postnatal home visits in two rural counties in Anhui Province, China.

Design

this was a mixed methods study which uses mainly qualitative methods including focus group discussions, in- depth interviews and key informant interviews. A household survey of postpartum women was used to calculate the rates of postnatal home visits.

Setting

two rural counties in Anhui Province, China.

Participants

qualitative study participants: officials responsible for maternal health care at county level, health providers at township and village level and maternal health-care users. Household survey participants: 2326 women who gave birth in the two counties from January 2005 to December 2006.

Findings

the survey of postpartum women revealed that only 4.2% and 4.5% of women received one or more postnatal visits at home in County A and County B. Qualitative interviews revealed a range of perceived reasons for this low rate of provision and utilisation of postnatal care, including: inadequate funding for maternal health care; limited human resources; lack of transport in township hospitals; and limited value placed on postnatal care by women and providers. In addition, where services were provided, a number of factors were likely to restrict health providers from delivering high-quality postnatal health service, such as: weak skills and knowledge of staff; inadequate in-service training; lack of equipment in township hospitals; and poor supervision and monitoring.

Key conclusions

the rate of postnatal visits was extremely low in two counties in rural China. Understaffing and inadequate funding are the main factors that affect provision of postnatal health care.

Implications for practice

more emphasis should be attached to political support and funding for postnatal care. Research into feasible ways to provide quality postnatal care needs to be conducted.     

An analysis of the meanings of pre-eclampsia for pregnant and postpartum women and health professionals in Rio Grande do Norte, Brazil

Objective

to understand the meanings of pre-eclampsia for pregnant and postpartum women and health-care professionals.

Design

a word-association test and semi-structured interviews.

Setting

a maternity hospital located in Natal, Rio Grande do Norte, Brazil that serves pregnant and postpartum women considered to be at high risk.

Participants

51 pregnant women, 10 postpartum women and 87 health-care professionals completed a word-association test; 18 pregnant women, two postpartum women and 20 health-care professionals for the interviews.

Measurements and findings

thematic categories based on the word-association test and the interviews were created to help the data analysis. χ² test was used to compare the categories raised by both groups in the word-association test to determine the association between the frequencies of these categories. The meanings of pre-eclampsia to pregnant and postpartum women were fear, risk, care and lack of information. To the health-care professionals, the meanings were care, fear, risk, high blood pressure, oedema and proteinuria. The frequencies of the categories ‘fear’, ‘care’ and ‘risk’ were statistically different (χ²=31.84, 14.5, 38.19, respectively; df=2, p<0.001) between the group of pregnant and postpartum women and the group of health-care professionals. For the first group, the most significant meanings were fear and risk, compared with care for the second group. The analysis of the interviews confirmed and deepened the results of the word-association test, and also demonstrated that the pregnant and postpartum women had no information about pre-eclampsia.

Key conclusions and implications for practice

there is a gap between how women and health professionals view their experiences of pre-eclampsia. A warm welcome to the health-care facility, with clear explanations about the disease and the procedures to be performed during the visits and hospitalisation would be important aspects for the physical and mental well-being of pregnant and postpartum women.     

Postpartum doulas: motivations and perceptions of practice

Objective

to describe the perceptions of a US cohort of experienced birth doulas who were among the first in the country to be trained to provide postpartum support.

Design

a qualitative, longitudinal study using ethnographic methods; participant observation and semi-structured interviews.

Setting

midwestern, urban, US; postpartum home care over three months.

Participants

four postpartum doulas; 13 families.

Measurements

participant observation during six postpartum home visits per family; 13 semi-structured interviews with doulas at the completion of each family’s care; four summative interviews with doulas at the end of the study.

Findings

when describing their postpartum practice, four themes emerged: supporting women, taking the mother’s perspective, empowering women and empowering families. When speaking of the motivations, three themes emerged: being ‘called’ to practice, interest in preventing negative experiences, and career development.

Key conclusions and implications for practice

in the US, new mothers see midwives and doctors sporadically after discharge from the hospital. Postpartum doulas fill this gap in continuity of care by providing support for families as they transition to life with their new infant. Understanding the beliefs, values and practices of these important paraprofessionals will help midwives effectively integrate postpartum doula care into the care of women and infants.     

Parents’ experiences of midwifery students providing continuity of care

Objective

the aim of this study was to gain knowledge and a deeper understanding of the value attached by parents to relational continuity provided by midwifery students to the woman and her partner during the childbearing process. The focus of the study was on the childbirth and the postnatal home visit.

Design/setting

in this pilot project by researchers at Sør-Trøndelag University College, Norway, six midwifery students provided continuity of care to 58 women throughout their pregnancy, birth and the postnatal period. One group interview of eight women and two group interviews of five men, based on the focus group technique, were conducted at the end of the project. Qualitative data were analysed through systematic text condensation.

Findings

the findings included two main themes: ‘trusting relationship’ and ‘being empowered’. The sub-themes of a ‘trusting relationship’ were ‘relational continuity’ and ‘presence’. For the women, relational continuity was important throughout the childbearing process, but the men valued the continuous presence during birth most highly. ‘Being empowered’ had two sub-themes: ‘individual care’ and ‘coping’. For the women, individual care and coping with birth were important factors for being empowered. The fathers highlighted the individual care as necessary to feel empowered for early parenting. The home visit of the student was highly appreciated. The relationship with the midwifery student could be concluded, and they had the opportunity to review the progression of the birth with the student who had been present during the birth. During the home visit, the focus was more on the experiences of pregnancy and birth than on what lay ahead.

Key conclusions

when midwifery students provided continuous care during pregnancy, birth and the postnatal period, both women and men experienced a trusting relationship. Relational continuity was important for women in the entire process, but for the men this was mostly important during childbirth. Individual care and coping with birth and early parenting enhanced empowerment. The limited sample size in this study means that it cannot be generalised without caution, and further research is needed.     

Social support provided to Finnish mothers and fathers by nursing professionals in the postnatal ward

Objectives

to evaluate the amount of social support offered to Finnish mothers and fathers by nursing professionals in the postnatal ward, identify the type of additional support that mothers and fathers desire, and analyse the factors associated with support that mothers and fathers received in the postnatal ward.

Methods

data were collected as part of a larger collaborative project called ‘Urban Parenthood—Enhancing Well-being of Infants’ Families’ involving the well-being of families in the postnatal wards of two Finnish university hospitals during the winter of 2006–2007. Data were collected using a questionnaire designed to measure social support on a scale from 1 to 6. The questionnaire included two open-ended questions. Mothers and fathers completed the questionnaire independently, either in the postnatal ward or immediately after discharge.

Findings

questionnaires were returned by 863 (66%) mothers and 525 (40%) fathers. The amount of support received from nursing professionals was moderate or little. Of the three types of support, mothers and fathers experienced ‘affectional support’ most strongly [mothers’ mean 4.12, standard deviation (SD) 1.04; fathers’ mean 3.98, SD 1.25] and ‘concrete support’ least strongly (mothers’ mean 3.08, SD 1.17; fathers’ mean 3.03, SD 1.43). Least social support was received by parents in families where the mother was multiparous (p<0.001) or older (p≤0.001), and by fathers who were not able to stay in the ward around the clock (p<0.001). Open-ended questions indicate that mothers and fathers desire greater social support in all its forms.

Key conclusions

health care during the postnatal period should be developed such that it becomes more family centred, encouraging and resource strengthening.

Implications for practice

Attention must be paid to the support received by older mothers and parents in families where the mother is multiparous. In addition, possibilities for fathers to participate in postnatal care must be increased.     

Caseload midwifery in a multi-ethnic community: The women's experiences

Objective

to evaluate caseload midwifery in a relatively deprived and ethnically diverse inner-city area.

Design and setting

semi-structured interviews were undertaken with 24 women from diverse ethnic backgrounds, 12 of whom had received caseload care and 12 women from an adjacent area who had received conventional maternity care in a large inner-city maternity unit. Framework analysis was adopted drawing on links with the authors' previous work on women's views of caseload midwifery.

Findings

key themes from previous work fitted well with the themes that emerged from this study. Themes included ‘knowing and being known’, ‘person-centred care’, ‘social support’, ‘gaining trust and confidence’, ‘quality and sensitivity of care’ and ‘communication’.

Key conclusions and implications

women from this socially and ethnically diverse group of women had similar views and wanted similar care to those in previous studies of caseload midwifery. Many of the women receiving caseload care highlighted the close relationship they had with the midwives and as a result of this felt more able to discuss their concerns with them. This has the potential not only for improved quality of care but also improved safety.     

Views of Chinese women and health professionals about midwife-led care in China

Aims

to explore Chinese women’s and health professionals’ views of the first midwife-led normal birth unit in China to facilitate normal birth and enhance midwifery practice.

Method

data collection involved semi-structured interviews, questionnaires and cross-comparison with hospital data. The data were analysed thematically.

Setting

a university teaching hospital in a major city in eastern China.

Participants

purposive sample of 30 women, five midwives and five medical staff who accessed, provided or liaised with the midwife-led service.

Main outcome measures

participants’ satisfaction, continuity of care/carers, choice and control.

Findings

informants were positive about the unit, largely because the woman was supported by a midwife and a birth companion through the ‘two-to-one’ model of care.

Discussion

the concept of ‘two-to-one’ care emerged as fundamental to women’s experiences and utilisation of midwives’ skills to promote normal birth. The high vaginal birth rate and the positive feelings reported suggest that this approach serves to empower women and promote physiological birth.

Conclusion

women appreciated the midwife-led service, which provides an environment where they are more likely to aim to give birth without intervention. This model of care is good for its association with increased satisfaction in a context of extraordinarily high caesarean rates.

Implications

midwife-led care can facilitate continuity of care and carer during birth. It offers women choice and control over many aspects of the birth. Further research is required to investigate factors important to women.     

‘Reacting to the unknown’: experiencing the first birth at home or in hospital in Australia

Objective

to explore the experiences of a small group of first-time mothers giving birth at home or in hospital.

Design

a grounded theory methodology was used. Data were generated from in-depth interviews with women in their own homes.

Setting

Sydney, Australia.

Participants

19 women were interviewed. Seven women who gave birth for the first time in a public hospital and seven women who gave birth for the first time at home were interviewed, and their experiences were contrasted with two mothers who gave birth for the first time in a birth centre, one mother who gave birth for the first time in a private hospital and two women who had given birth more than once.

Results

these women shared common experiences of giving birth as ‘novices’. Regardless of birth setting, they were all ‘reacting to the unknown’. As they entered labour, the women chose different levels of responsibility for their birth. They also readjusted their expectations when the reality of labour occurred, reacted to the ‘force’ of labour, and connected or disconnected from the labour and eventually the baby.

Implications for practice

knowing that first-time mothers, irrespective of birth setting, are essentially ‘reacting to the unknown’ as they negotiate the experience of birth, could alter the way in which care is provided and increase the sensitivity of midwives to women's needs. Most importantly, midwives need to be aware of the need to help women adjust their expectations during labour and birth. Identifying the ‘novice’ status of first-time mothers also better explains previous research that reports unrealistic expectations and fear that may be associated with first-time birthing.     

A hermeneutic phenomenological study of Belgian midwives' views on ideal and actual maternity care

Objective

to explore midwives' views on ideal and actual maternity care.

Design

a qualitative hermeneutic phenomenological study based on the method of van Manen (1997) using individual in-depth interviews to gather data.

Setting

Flanders, Belgium.

Participants

12 purposively sampled midwives, of whom nine from three different non-university hospitals and three independent midwives conducting home births.

Findings

five major themes were identified: ‘woman-centred care’, ‘cultural change’, ‘support’, ‘midwife and obstetrician as equal partners’ and ‘inter-collegial harmony’. In this paper ‘woman-centred care’, ‘cultural change’ and ‘support’ are discussed along with their subthemes. Midwives thought ideal maternity care should be woman-centred in which there were no unnecessary interventions, women were able to make an informed choice and there was continuity of care. Furthermore, ideal maternity care should be supported by midwifery education and an adequate staffing level. Also, a cultural change was wanted as actual maternity care was perceived to be highly medicalised. Barriers to achieving woman-centred care and possible strategies to overcome these were described.

Conclusions

findings from this study were consistent with those of other studies on midwives' experience with obstetric-led care. Despite the medicalised care, midwives still held a woman-centred ideology. In order to be able to work according to their ideology, different barriers need to be addressed. Although midwives suggested strategies to overcome these barriers, some were considered to be very difficult to overcome.     

Pregnancy health status of sub-Saharan refugee women who have resettled in developed countries: a review of the literature

Objective

to present the literature relating to health status and pregnancy complications among sub-Saharan African women.

Background

sub-Saharan refugee women constitute a new and growing group of maternity service users in developed countries today. These women are perceived to be at high risk of pregnancy complication, based on concurrent disease and unusual medical conditions. As a result of these concerns, midwives may feel ill equipped to provide their pregnancy care.

Method

searches were conducted of CINAHL, Maternity and Infant Care, MEDLINE and PsychINFO databases using the search terms ‘migrants’, ‘Africa’, ‘sub-Saharan’, ‘pregnancy’, ‘refugees’ and ‘women’. Additional articles were located by pursuing references identified in key papers.

Findings

pregnant sub-Saharan women present as an at-risk population related to poor prior health, co-existing disease and cultural practices such as female genital mutilation. Nonetheless, principal pregnancy complications for this population include anaemia and high parity, rather than exotic disease. Higher rates of infant mortality and morbidity appear to persist following resettlement, and are not explained by maternal risk factors alone. Limited access to care is of concern.

Key conclusions

further research is warranted into the impediments to care uptake among sub-Saharan African women. It is hoped that such research will inform the development of culturally appropriate and acceptable services for African refugees.

Implications for practice

it is important that midwives are aware of common health problems among sub-Saharan women. Midwives also need to act to promote access to health services among this group. Social disadvantage and late access to care may impact on neonatal outcomes and thus warrant investigation.     

Realities,difficulties, and outcomes for mothers choosing to breastfeed: Primigravid mothers experiences in the early postpartum period (6–8 weeks)

Objective

to develop an understanding of primiparous women's experiences and challenges of breast feeding in the early postpartum period at two BFI accredited hospitals in the East Midlands in the UK that has lower rates of sustained breast feeding.

Design and setting

a hermeneutic or interpretive phenomenology study was conducted across two hospitals in the East Midlands, UK.

Data collection

22 primigravid women completed a daily written diary maintained for six weeks post birth. In addition, interviews were conducted with 13 women, nine who had completed a diary and four who did not return a diary but wanted to be interviewed, providing 26 different women's perspectives on their breast feeding experiences either from a diary or interview.

Findings

three main themes emerged from the interviews and written diaries: (1) mothers experience a ‘roller coaster’ of emotions in relation to trying to establish breast feeding, (2) mothers perceive health care professionals as the ‘experts’ on breast feeding and (3) mothers had difficulties in breast feeding their infants in public, including in front of family and family and when away from their homes.

Conclusions

women were ill prepared for the realities of breast feeding despite their antenatal intention to breast feed. Mothers had a preconceived idea that breast feeding would be ‘natural’ and without difficulty. When problems occurred, they perceived this to be a breast feeding problem and so choose artificial milk. Mothers require ongoing support to breast feed, especially in the early postpartum period, but more realistic messages about breast feeding need to be included.

Implications for practice

there is a clear need for antenatal education to focus on preparing women for the realities of breast feeding, including newborn behaviour, which may affect women's perceptions of breast feeding. Local health care professionals need to draw upon national breast feeding strategies but develop a localised approach in order to address the regional variance.     

Clinical outcomes of the first midwife-led normal birth unit in China: a retrospective cohort study

Aims

to report the clinical outcomes of the first six months of operation of an innovative midwife-led normal birth unit (MNBU) in China in 2008, aiming to facilitate normal birth and enhance midwifery practice.

Setting

an urban hospital with 2000–3000 deliveries per year.

Method

this study was part of a major action research project that led to implementation of the MNBU. A retrospective cohort and a questionnaire survey were used. The data were analysed thematically.

Participants

the outcomes of the first 226 women accessing the MNBU were compared with a matched retrospective cohort of 226 women accessing standard care. In total, 128 participants completed a satisfaction questionnaire before discharge.

Main outcome measure

mode of birth and model of care.

Findings

the vaginal birth rate was 87.6% in the MNBU compared with 58.8% in the standard care unit. All women who accessed the MNBU were supported by both a midwife and a birth companion, referred to as ‘two-to-one’ care. None of the women labouring in the standard care unit were identified as having a birth companion.

Discussion

the concept of ‘two-to-one’ care emerged as fundamental to women’s experiences and utilisation of midwives’ skills to promote normal birth and decrease the likelihood of a caesarean section.

Conclusion

the MNBU provides an environment where midwives can practice to the full extent of their role. The high vaginal birth rate in the MNBU indicates the potential of this model of care to reduce obstetric intervention and increase women’s satisfaction with care within a context of extraordinary high caesarean section rates.

Implications for practice

midwife-led care implies a separation of obstetric care from maternity care, which has been advocated in many European countries.     

'Stay home for as long as possible': midwives' priorities and strategies in communicating with first-time mothers in early labour

Purpose

to explore the priorities and strategies midwives in a labour ward use in their communication with primiparous women who seek contact in the early phase of labour.

Design

a qualitative study using focus groups.

Setting

Norway.

Participants

18 midwives.

Findings

five themes that seemed to constitute the key elements in the communication were identified. The themes were designated ‘Getting the picture’, ‘Normalising the situation’, ‘Giving concrete advice’, ‘Letting the woman make the decision’, and ‘Staying at home for as long as possible’.

Conclusions and implications

the findings of this study indicate that the midwives' overall strategy was to encourage women to remain out of hospital for as long as possible ‘for their own good’. This strategy seems to rely on knowledge derived from non-contextual science within the dominant medical childbirth paradigm, and might not meet women's needs in early labour. When women are admitted in early labour, midwives should be able to ‘protect’ these women from unnecessary interventions and do so in partnership with the women themselves rather than accepting that women's mere presence in the labour ward yields complications and increases the likelihood of caesarean section. From the findings of this study, it is reasonable to ask whether an obstacle to this course might be the midwives’ subordination to the medical paradigm. This causes midwives to function as ‘gatekeepers’ to the medical system instead of working in accordance with the philosophy of midwifery: ‘for women's own good’.