Swedish women's experiences of seeking care and being admitted during the latent phase of labour: a grounded theory study

Objective

to gain a deeper understanding of how women who seek care at an early stage experience the latent phase of labour.

Design

a qualitative interview study using the grounded theory approach.

Setting

the study was conducted at a hospital in the southwestern part of Sweden with a range of 1600–1700 deliveries per year. The interviews took place in the women's homes two to six weeks after birth.

Participant

eighteen Swedish women, aged 22–36, who were admitted to the labour ward while they were still in the latent phase of labour.

Findings

‘Handing over responsibility’ to professional caregivers emerged as the core category or the central theme in the data. The core category and five additional categories formed a conceptual model explaining what it meant to women being admitted in the early stage of labour and their experiences of the latent phase of labour. The categories, which all related to the core category, were labelled: (1) ‘longing to complete the pregnancy,’ (2) ‘having difficulty managing the uncertainty,’ (3) ‘having difficulty enduring the slow progress,’ (4) ‘suffering from pain to no avail’ and (5) ‘oscillating between powerfulness and powerlessness.’

Conclusions and implications for practice

findings indicate that women being admitted to the labour ward in the latent phase of labour experienced a need for handing over responsibility for the labour, the well-being of the unborn baby, and for themselves. Midwives have an important role in assisting women with coping during the latent phase of labour, and in giving the women opportunity to hand over responsibility. This care should include validation of experienced pain and confirmation of the normality of the slow process, information and support.     

Development and psychometric testing of the scales for measuring maternal satisfaction in normal and caesarean birth

Objective

to develop a scale to measure maternal satisfaction with birth to evaluate women's experiences in labour and the early postpartum period.

Design

development and psychometric assessment of a multidimensional maternal satisfaction questionnaire.

Setting

maternity unit of a university hospital in Istanbul.

Participants

500 healthy postpartum women.

Methods

five steps were taken in development of the scale: literature review, generating item pool, content validity testing, administration of draft scale and psychometric testing. Two versions of the scale were developed: the Scale for Measuring Maternal Satisfaction–normal birth and the Scale for Measuring Maternal Satisfaction–caesarean birth. Content validity was evaluated by experts. The appropriate draft scale and the Newcastle Satisfaction with Nursing Scale were administered to postpartum women before hospital discharge.

Findings

content validity index scores for the vaginal and caesarean birth scales were 0.91 and 0.89, respectively. Item-total and subscale-total scores correlated significantly for each scale. Evaluation of construct validity through factor analysis yielded 10 subscales: ‘perception of health professionals’, ‘nursing/midwifery care in labour (in caesarean version: preparation for caesarean)’, ‘comforting’, ‘information and involvement in decision making’, ‘meeting baby’, ‘postpartum care’, ‘hospital room’, ‘hospital facilities’, ‘respect for privacy’ and ‘meeting expectations’. Both scales had good internal reliability, with Cronbach's α coefficients of 0.91. The scales established their convergent validity with significant correlations with the Newcastle Satisfaction with Nursing Scale.

Conclusion

the scales are valid and reliable tools for evaluating Turkish women's experiences in labour and the early postpartum period.

Implications for practice

the scales can contribute to the assessment of women's satisfaction with different aspects of care, the quality of care and developments in maternity services.     

The best of both worlds--parents' motivations for using an alongside birth centre from an ethnographic study

Objective and design

an ethnographic study was undertaken in a birth centre to explore the model of care provided there from the perspectives of midwives and parents.

Setting

a five birthing-room, alongside, inner-city, birth centre in England, situated one floor below the hospital labour ward, separately staffed by purposively recruited midwives.

Participants

around 114 hours were spent at the birth centre observing antenatal, intrapartum and postnatal care; 11 in-depth interviews were recorded with parents after their baby's birth (four with women; seven with women and men together), including three interviews with women who transferred to the labour ward, and 11 with staff (nine midwives and two maternity assistants).

Findings

most women and men using the birth centre perceived it as offering the ‘best of both worlds’ based on its proximity to and separation from the labour ward. It seemed to offer a combination of biopsychosocial safety, made evident by the calm, welcoming atmosphere, the facilities, engaging, respectful care from known midwives and a clear commitment to normal birth, and obstetric safety particularly because of its close proximity to the labour ward.

Key conclusions and implications for practice

this alongside birth centre provided a social model of care and appealed strongly to a group of parents; similar birth centres should be widely available throughout the NHS.     

The novice birthing: theorising first-time mothers' experiences of birth at home and in hospital in Australia

Objective

to explore first-time mothers’ experiences of birth at home and in hospital in Australia.

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 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.

Findings

three categories emerged from the analysis: preparing for birth, the novice birthing and processing the birth. These women shared a common core experience of seeing that they gave birth as ‘novices’. The basic social process running through their experience of birth, regardless of birth setting, was that, as novices, they were all ‘reacting to the unknown’. The mediating factors that influenced the birth experiences of these first-time mothers were preparation, choice and control, information and communication, and support. The quality of midwifery care both facilitated and hindered these needs, contributing to the women's perceptions of being ‘honoured’. The women who gave birth at home seemed to have more positive birth experiences.

Implications for practice

identifying the novice status of first-time mothers and understanding the way in which they experience birth better explains previous research that reports unrealistic expectations and fear that may be associated with first-time birthing. It demonstrates how midwives can contribute to positive birth experiences by being aware that first-time mothers, irrespective of birth setting, are essentially reacting to the unknown as they negotiate the experience of birth.     

Midwives' experiences of doula support for immigrant women in Sweden--a qualitative study

Objective

to describe and analyse midwives’ experiences of doula support for immigrant women in Sweden.

Design

qualitative study, analysed using content analysis. Data were collected via interviews.

Setting

interviews were conducted at the midwives’ workplaces. One midwife was interviewed at a cafe.

Participants

ten midwives, who participated voluntarily and worked in maternity health care in western Sweden.

Findings

the interview data generated three main categories. (1) ‘A doula is a facilitator for the midwife’ has two subcategories, ‘In relation to the midwife’ and ‘In comparison with an interpreter’, (2) ‘Confident women giving support,’ has two subcategories, ‘Personal characteristics and attitudes’ and ‘Good support,’ (3) ‘Doulas cover shortcomings’ has two subcategories, ‘In relation to maternity care’ and ‘In relation to ethnicity’.

Key conclusion and implications for practice

The findings of this study show that midwives experience that doulas are a facilitator for them. Doulas provide support by enhancing the degree of peace and security and improving communication with the women in childbirth. Doulas provide increased opportunities for transcultural care. They may increase childbearing women's confidence and satisfaction, help meet the diverse needs of childbearing women and improve care quality.     

Randomised-controlled trial of two antenatal education programmes

Objective

to determine whether a new antenatal education programme with increased parenting content could improve parenting outcomes for women compared with a regular antenatal education programme.

Design

a randomised-controlled trial. Data were collected through self-report surveys.

Setting

specialist referral maternity hospital in Sydney, Australia.

Participants

170 women birthing at the hospital. Ninety-one women attended the new programme and 79 the regular programme.

Intervention

a new antenatal education programme (‘Having a Baby’ programme) developed from needs assessment data collected from expectant and new parents. One important feature of the programme was the recognition that pregnancy, labour, birth and early parenting were a microcosm of the childbearing experience, rather than separate topics.

Measures

the primary outcome measure was perceived maternal parenting self-efficacy. Worry about the baby, and perceived parenting knowledge, were secondary outcome measures. They were measured before the programme and after birth. Birth outcomes were also recorded.

Findings

the postnatal perceived maternal parenting self-efficacy scores of women who attended the ‘Having a Baby’ programme were significantly higher than those who attended the regular programme. Perceived parenting knowledge scores of women who attended the ‘Having a Baby’ programme were also significantly higher than those who attended the regular programme. Worry scores were lower but they did not reach statistical significant. Birth outcomes were similar.

Implications for practice

the ‘Having a Baby’ programme improved maternal self-efficacy and parenting knowledge. Parenting programmes that continue in the early postnatal period may be beneficial.     

‘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.     

Women's experience with early labour management at home vs. in hospital: A randomised controlled trial

Objective

to compare experiences with early labour assessment and support at home vs. by telephone.

Design

a randomised controlled trial of nurse home visits vs. telephone support for assessment and support of women in early labour.

Setting

hospitals serving obstetrical populations in metropolitan and suburban Vancouver, British Columbia, Canada.

Participants

healthy nulliparous women in labour at term with uncomplicated pregnancies participating in the third and fourth year of the trial.

Intervention

women were randomised to receive early labour assessment and support at home (n=241) and or to receive assessment and support by telephone (n=182).

Measurement

the Early Labour Experience Questionnaire (ELEQ), a 26-item self-administered questionnaire that measures women's experience with early labour care across three domains: emotional well-being, emotional distress and perceptions of nursing care.

Findings

women who received home visits rated their early labour experience more positively overall compared to women who received telephone support (103.14±12.45 vs. 99.67±13.11, p<.01)including perceptions of nursing care that they received (38.64±2.90 vs. 36.82±4.09, p<.001). However, women's affective experiences did not differ.

Key conclusions

early labour nursing care provided at home is associated with a more positive experience of early labour compared to telephone support.     

Influence on birthing positions affects women's sense of control in second stage of labour

Objective

to explore whether choices in birthing positions contributes to women's sense of control during birth.

Design

survey using a self-report questionnaire. Multiple regression analyses were used to investigate which factors associated with choices in birthing positions affected women's sense of control.

Setting

midwifery practices in the Netherlands.

Participants

1030 women with a physiological pregnancy and birth from 54 midwifery practices.

Findings

in the total group of women (n=1030) significant predictors for sense of control were: influence on birthing positions (self or self together with others), attendance of antenatal classes, feelings towards birth in pregnancy and pain in second stage of labour. For women who preferred other than supine birthing positions (n=204) significant predictors were: influence on birthing positions (self or self together with others), feelings towards birth in pregnancy, pain in second stage of labour and having a home birth. For these women, influence on birthing positions in combination with others had a greater effect on their sense of control than having an influence on their birthing positions just by themselves.

Key conclusions

women felt more in control during birth if they experienced an influence on birthing positions. For women preferring other than supine positions, home birth and shared decision-making had added value.

Implications for practice

midwives can play an important role in supporting women in their use of different birthing positions and help them find the positions they feel most comfortable in. Thus, contributing to women's positive experience of birth.     

The influences on women who choose publicly-funded home birth in Australia

Objective

to explore the influences on women who chose a publicly-funded home birth in one Australian state.

Design

a constructivist grounded theory methodology was used.

Setting

a publicly-funded home birth service located within a tertiary referral hospital in the southern suburbs of Sydney, Australia.

Participants

data were collected though semi-structured interviews of 17 women who chose to have a publicly-funded home birth.

Findings

six main categories emerged from the data. These were feeling independent, strong and confident, doing it my way, protection from hospital related activities, having a safety net, selective listening and telling, and engaging support. The core category was having faith in normal. This linked all the categories and was an overriding attitude towards themselves as women and the process of childbirth. The basic social process was validating the decision to have a home birth.

Conclusion

women reported similar influences to other studies when choosing home birth. However, the women in this study were reassured by the publicly-funded system?s ‘safety net’ and apparent seamless links with the hospital system. The flexibility of the service to permit women to change their minds to give birth in hospital, and essentially choose their birthplace at any time during pregnancy or labour was also appreciated.

Implications for practice

women that choose a publicly-funded home birth service describe strong influences that led them to home birth within this model of care. Service managers and health professionals need to acknowledge the importance of place of birth choice for women.     

Does counsellor's attitude influence change in a request for a caesarean in women with fear of birth?

Background

the attitudes of two counsellors towards women requesting a caesarean section due to fear of birth were identified. One emphasised the ability to overcome any emotional obstacle to vaginal birth (‘coping attitude’), and the other emphasised that the ultimate choice of mode of birth was the womans’ (‘autonomy attitude’). Two research questions were asked: (1) What are the predictors of change in a wish for a caesarean and of vaginal birth in women with fear of birth? (2) Does a change from an ‘autonomy attitude’ to a ‘coping attitude’ increase the number of women who change their request for a caesarean and who give birth vaginally?

Methods

the study population consisted of two samples of pregnant women with fear of birth and concurrent request for a caesarean, referred for crisis-oriented counselling at the antenatal clinic, University Hospital of North Norway between 2000–2002 (n=86) and 2004–2006 (n=107). Data were gathered from referral letters, counseling and antenatal, intra- and postpartum records.

Findings

a coping attitude of the counsellor was positively associated with change in the request for a caesarean and with vaginal birth. A change from an autonomy attitude to a coping attitude was associated with a significant increase in the percentage of women who changed their desire for a caesarean from 77 to 93, and who had a vaginal birth from 42 to 81.

Conclusion

a coping attitude was strongly associated with change in the desire for a caesarean and giving birth vaginally. A coping attitude can be learned through critical reflection and awareness of the counsellor's attitude, with measurable clinical results.     

Why home birth? A qualitative study exploring women's decision making about place of birth in two Canadian provinces

Objective

the aim of this study was to increase our understanding of why Canadian women choose to give birth at home. Despite on-going debate regarding the safety of home birth, a small number of Canadian women choose home as a place to give birth. The factors influencing a woman's decision to plan a home birth remain poorly understood.

Design

a qualitative, grounded theory approach using semi-structured interviews.

Participants

a purposive sample of women from two Canadian provinces, who planned to give birth at home in their current pregnancy or who had planned a home birth within the last 2 years.

Findings

thematic analysis highlighted key motivating factors as well as a decision-making framework by which women chose home birth. The decision making process includes an exploration of internal motivators for wanting home birth, a phase of information gathering and taking ownership for the decision to give birth at home.

Key conclusions

the study showed that women in two geographically distinct parts of Canada approach decision making around home birth in a similar fashion and provides a framework for decision making for choosing to birth at home.

Implications for practice

improved understanding of the decision making process for choice of birth place is useful for midwives for the provision of information to their clients and for midwifery policy and practice within Canada.     

Midwives' experiences of facilitating normal birth in an obstetric-led unit: a feminist perspective

Objective

to explore midwives’ experiences of facilitating normal birth in an obstetric-led unit.

Design

a feminist approach using semi-structured interviews focusing on midwives’ perceptions of normal birth and their ability to facilitate this birth option in an obstetric-led unit.

Setting

Ireland.

Participation

a purposeful sample of 10 midwives with 6–30 years of midwifery experience. All participants had worked for a minimum of 6 years in a labour ward setting, and had been in their current setting for the previous 2 years.

Findings

the midwives’ narratives related to the following four concepts of patriarchy: ‘hierarchical thinking’, ‘power and prestige’, ‘a logic of domination’ and ‘either/or thinking’ (dualisms). Two themes, ‘hierarchical thinking’ and ‘either/or thinking’, (dualisms) along with their subthemes are presented in this paper.

Key conclusions and implications for practice

this study identified some of the reasons why midwives find it difficult to facilitate normal birth in an obstetric unit setting, and identified a need for further research in this area. Midwifery education and supportive management structures are required if midwives are to become confident practitioners of normal birth.     

HIV-positive women's experiences of a PMTCT programme in rural Malawi

Objective

to explore women's experiences of a prevention of mother-to-child transmission (PMTCT) programme in rural Malawi.

Design, setting and participants

an exploratory, qualitative study using in-depth interviews with 24 purposively selected women infected with human immunodeficiency virus (HIV). The women were in three groups of eight: (1) those who delivered at the hospital and took nevirapine (NVP) before birth and whose babies received NVP within 72 hours of birth; (2) those who birthed at home and took NVP before birth but their babies never received NVP; and (3) those who birthed at home and did not take NVP and whose babies did not receive NVP. Data were analysed using content analysis.

Findings

four themes emerged: (1) ‘a wish to confirm and protect’ refers to women's decisions to take the HIV test, (2) ‘a revelation for action’ is an illustration of how the testing may be part of an empowering process, (3) ‘a dilemma between silence and openness’ points to the dilemma that women are facing in their decision to share or not to share their HIV status with spouse, family, friends and community, and (4) ‘a desire challenged by circumstances, chance and tradition’ refers to the circumstances and actions which prevent these women from actually delivering at the hospital to protect their babies from HIV infection.

Conclusions

the PMTCT programme influences women's lives profoundly, and the importance of quality counselling and strengthening male involvement is stressed as the programme is implemented by an increasing number of service providers.     

Home care after early discharge: Impact on healthy mothers and newborns

Objective

to compare early discharge with home care versus standard postpartum care in terms of mothers' sense of security; contact between mother, newborn and partner; emotions towards breast feeding; and breast-feeding duration at one and three months after birth.

Design

retrospective case-control study.

Setting

a labour ward unit in Stockholm, Sweden handling both normal and complicated births.

Participants

96 women with single, uncomplicated pregnancies and births, and their healthy newborns.

Intervention

early discharge at 12–24 hours post partum with 2–3 home visits during the first week after birth. The intervention group consisted of women who had a normal vaginal birth (n=45). This group was compared with healthy controls who received standard postnatal care at the hospital (n=51).

Instruments

mothers' sense of security was measured using the Parents' Postnatal Sense of Security Scale. Contact between mother, child and father, and emotions towards breast feeding were measured using the Alliance Scale, and breast-feeding rates at one and three months post partum were recorded.

Findings

women in the intervention group reported a greater sense of security in the first postnatal week but had more negative emotions towards breast feeding compared with the control group. At three months post partum, 74% of the newborns in the intervention group were fully breast fed versus 93% in the control group (p=0.021). Contact between the mother, newborn and partner did not differ between the groups.

Conclusion

early discharge with home care is a feasible option for healthy women and newborns, but randomised controlled studies are needed to investigate the effects of home care on breast-feeding rates.     

Safe Delivery Posts: An intervention to provide equitable childbirth care services to vulnerable groups in Zahedan,Iran

Background

recently, there has been a shift towards alternative childbirth services to increase access to skilled care during childbirth.

Objective

this study aims to assess the past 10 years of experience of the first Safe Delivery Posts (SDPs) established in Zahedan, Iran to determine the number of deliveries and the intrapartum transfer rates, and to examine the reasons why women choose to give birth at a Safe Delivery Post and not in one of the four large hospitals in Zahedan.

Design

a mixed-methods research strategy was used for this study. In the quantitative phase, an analysis was performed on the existing data that are routinely collected in the health-care sector. In the qualitative phase, a grounded theory approach was used to collect and analyse narrative data from in-depth interviews with women who had given birth to their children at the Safe Delivery Posts.

Setting

women were selected from two Safe Delivery Posts in Zahedan city in southeast Iran.

Participants

nineteen mothers who had given birth in the Safe Delivery Posts were interviewed.

Findings

during the 10-year period, 22,753 low-risk women gave birth in the Safe Delivery Posts, according to the records. Of all the women who were admitted to the Safe Delivery Posts, on average 2.1% were transferred to the hospital during labour or the postpartum period. Three key categories emerged from the analysis: barriers to hospital use, opposition to home birth and finally, reasons for choosing the childbirth care provided by the SDPs.

Key conclusion and implications for practice

implementing a model of midwifery care that offers the benefits of modern medical care and meets the needs of the local population is feasible and sustainable. This model of care reduces the cost of giving birth and ensures equitable access to care among vulnerable groups in Zahedan.     

The Canadian Birth Place Study: Describing maternity practice and providers' exposure to home birth

Objectives

(1) to describe educational, practice, and personal experiences related to home birth practice among Canadian obstetricians, family physicians, and registered midwives; (2) to identify barriers to provision of planned home birth services, and (3) to examine inter-professional differences in attitudes towards planned home birth.

Design

the first phase of a mixed-methods study, a quantitative survey, comprised of 38 items eliciting demographic, education and practice data, and 48 items about attitudes towards planned home birth, was distributed electronically to all registered midwives (N=759) and obstetricians who provide maternity care (N=800), and a random sample of family physicians (n=3,000).

Setting

Canada. This national investigation was funded by the Canadian Institutes for Health Research.

Participants

Canadian registered midwives (n=451), obstetricians (n=245), and family physicians (n=139).

Findings

almost all registered midwives had extensive educational and practice experiences with planned home birth, and most obstetricians and family physicians had minimal exposure. Attitudes among midwives and physicians towards home birth safety and advisability were significantly different. Physicians believed that home births are less safe than hospital births, while midwives did not agree. Both groups believed that their views were evidence-based. Midwives were the most comfortable with including planned home birth as an option when discussing choice of birth place with pregnant women. Both midwives and physicians expressed discomfort with inter-professional consultation related to planned home births. In addition, both family physicians and obstetricians reported discomfort with discussing home birth with their patients. A significant proportion of family physicians and obstetricians would have liked to attend a home birth as part of their education.

Conclusions

the amount and type of education and exposure to planned home birth practice among maternity care providers were associated with attitudes towards home birth, comfort with discussing birth place options with women, and beliefs about safety. Barriers to home birth practice across professions were both logistical and philosophical.

Implications for practice

formal mechanisms for midwifery and medical education programs to increase exposure to the theory and practice of planned home birth may facilitate evidence based informed choice of birth place, and increase comfort with integration of care across birth settings. An increased focus among learners and clinicians on reliable methods for assessing the quality of the evidence about birth place and maternal-newborn outcomes may be beneficial.