Birth place preferences and women’s expectations and experiences regarding duration and pain of labor

Introduction: We know a great deal about how childbirth is affected by setting; we know less about how the experience of birth is shaped by the attitudes women bring with them to the birthing room. In order to better understand how women frame childbirth, we examined the relationship between birth place preference and expectations and experiences regarding duration of labor and labor pain in healthy nulliparous women.

Methods: A prospective cohort study (2007–2011) of 454 women who preferred a home birth (n?=?179), a midwife-led hospital birth (n?=?133) or an obstetrician-led hospital birth (n?=?142) in the Netherlands. Data were collected using three questionnaires (before 20 weeks gestation, 32 weeks gestation and 6 weeks postpartum) and medical records. Analyses were performed according to the initial preferred place of birth.

Results: Women who preferred a home birth were significantly less likely to be worried about the duration of labor (OR 0.5, 95%CI 0.2–0.9) and were less likely to expect difficulties with coping with pain (OR 0.4, 95%CI 0.2–0.8) compared with women who preferred an obstetrician-led birth. We found no significant differences in postpartum accounts of duration of labor. When compared to women who preferred an obstetrician-led birth, women who preferred a home birth were significantly less likely to experience labor pain as unpleasant (OR 0.3, 95%CI 0.1–0.7). Women who preferred a midwife-led birth – either home or hospital – were more likely to report that it was not possible to make their own choices regarding pain relief compared to women who preferred obstetrician-led care (OR 4.3, 95%CI 1.9–9.8 resp. 3.4, 95%CI 1.5–7.7). Compared to women who preferred a midwife-led hospital birth, women who preferred a home birth had an increased likelihood of being dissatisfied about the management of pain relief (OR 2.5, 95%CI 1.1–6.0).

Discussion: Our findings suggest a more natural orientation toward birth with the acceptance of labor pain as part of giving birth in women with a preference for a home birth. Knowledge about women’s expectations and experiences will help caregivers to prepare women for childbirth and will equip them to advise women on birth settings that fit their cognitive frame.     

‘Tough love’: The experiences of midwives giving women sterile water injections for the relief of back pain in labour

ObjectiveTo explore midwives’ experiences of administering sterile water injections (SWI) to labouring women as analgesia for back pain in labour.DesignA qualitative study, which generated data through semi-structured focus group interviews with midwives. Data were analysed thematically.SettingTwo metropolitan maternity units in Queensland, Australia.ParticipantsEleven midwives who had administered SWI for back pain in labour in a randomised controlled trial.FindingsThree major themes were identified including: i. SWI, is it an intervention?; ii. Tough love, causing pain to relieve pain; iii. The analgesic effect of SWI and impact on midwifery practice.Key conclusionsWhilst acknowledging the potential benefits of SWI as an analgesic the midwives in this study described a dilemma between inflicting pain to relieve pain and the challenges encountered in their discussions with women when offering SWI. Midwives also faced conflict when women requested SWI in the face of institutional resistance to its use.Implications for practiceThe procedural pain associated with SWI may discourage some midwives from offering women the procedure, providing women with accurate information regarding the intensity and the brevity of the injection pain and the expected degree of analgesic would assist in discussion about SWI with women.     

Student midwives’ experiences in relation to assessment of maternal postnatal genital tract health: A case study analysis

Objectiveto explore student midwives’ experiences of postnatal genital tract assessment within midwifery preregistration curricula.Designa single, instrumental case study design was employed involving final year student midwives. Ethical approval was gained from the Higher Education Institution at the data collection site. Sampling was purposeful and data were collected using a survey (n = 25); narrative style in depth interviews (n = 11), review of programme documentation and a student midwife / researcher data workshop.Settingone Higher Education Institution in the north of England.Findingsthree themes were identified from the data analysis, awareness of assessment methods, accessing learning opportunities and actualisation of learning. The awareness theme highlights that most students were aware of potential signs and symptoms associated with genital tract assessment and health however; difficulties were identified concerning assessment of lochia, encountering sequential assessments and recognising potential for deterioration. This awareness was influenced by access to practice based learning opportunities. Access differed due to variation in postnatal provision, service pressures and variety in mentor practices regarding selecting and creating learning opportunities. This study suggests actualisation of learning and confidence in genital tract assessment was achieved when opportunities to integrate theory and practice occurred. Actualisation was hindered by limited allocation of curriculum time specifically for postnatal maternal assessment content and assessment strategies in comparison to other aspects of midwifery knowledge.Conclusionsstudent midwives’ experiences, awareness and learning actualisation varied in relation to the development of knowledge and confidence in maternal postnatal genital tract assessment. While clinical and theoretical learning opportunities were available, access and experience varied and limitations were identified. A number of recommendations are outlined to enhance the students learning experiences in practice and HEI settings, which address placement planning, mentor preparation, the student voice and supporting curricula documentation.     

A focus group study of women’s views and experiences of maternity care as delivered collaboratively by midwives and health visitors in England

Background

Research suggests that collaboratively delivered maternity care can positively impact health outcomes. However, women’s perspectives on models of care involving interprofessional collaboration between midwives and health visitors are not well understood. Accounts of women’s maternity care experiences are key to improving maternity services. This study considered women’s views and experiences of maternity care as collaboratively provided by midwives and health visitors in England.

Methods

A qualitative focus group study with an exercise exploring women’s ideal maternity care pathway was conducted. Three focus groups were conducted in London, England between June and August 2017 with women who had had a child within 18?months prior to the study. The participants (n?=?12) were recruited from two Children’s Centres in London, England. Data were analysed using thematic analysis.

Results

Four themes were identified: ‘Women’s experiences of maternity care from midwives and health visitors’, ‘Midwife-health visitor communication’, ‘Midwife-health visitor collaboration for tailored care’, and ‘Women’s ideal maternity care pathway’. Regarding women’s experiences of interprofessional collaboration between midwives and health visitors, this was rarely encountered, but welcomed by women. Women’s observations of limited tailored care and co-ordination led to several suggestions to improve maternity care, including secure, shared medical recordkeeping systems, clarity on midwives’ and health visitors’ roles, as well as increased communication.

Conclusions

Maternity care that is collaboratively delivered by midwives and health visitors, from the perspectives of the women in this study, is not routinely provided. However, women recognise the potential benefits of midwife-health visitor collaboration. Future research should explore service configurations that support integrated maternity care pathways, and evaluate the impact of midwife-health visitor collaboration on health and service outcomes.

     

Swedish midwives’ experiences and views of amniotomy: An interview study

ObjectiveTo explore midwives’ experiences and views of amniotomy.DesignA qualitative inductive design was used. Data were collected using interviews and analysed with content analysis carried out with NVivo 12.Setting and participantsSixteen midwives working at delivery wards at three hospitals in the south of Sweden.FindingsThree categories emerged: “Promote, protect and support the physiological process of labour”, “To make the decision -to do or not to do” and “Unpredictable response”. The overall theme linking the three categories was “We become our decisions”, portraying how midwives carry the responsibility in the decision-making and represent themselves in their handling of amniotomy.ConclusionsAmniotomy was experienced and viewed as both simple and complex, safe and risky, and deciding on it sometimes implied balancing contradicting perspectives. By using midwifery skills in the decision-making for an amniotomy, the midwives tried to predict the response, purposing to support physiological labour and promote health for women and babies.     

Going back to work after childbirth: women’s lived experiences

Objective: The study aimed at understanding the experiences of first-time mothers who returned to work after paid maternity leave. It explored the challenges new mothers faced during the transition of having a baby, taking 14 weeks of paid maternity leave and then returning to work. Background: Traditionally women left paid employment and stayed at home while their children were still young, but recent times have seen a change in local women’s labour force participation and the actual lived experiences of Maltese women in the context of transition to parenthood had not been explored. Society still seems to expect that the idea of balancing work and family life is principally a women’s issue as traditional gender roles still appear to prevail. Methods: The qualitative paradigm was used to conduct the study by means of a semi-structured interview schedule at three different phases throughout the experience. Ten women were chosen to participate in this study by purposive sampling. The theoretical framework used to guide this thesis included phenomenology, transitional theory as described by van Gennep and feminism. Interpretative phenomenological analysis was used during the analysing phase. Results: The resulting three super-ordinate themes identified how after childbirth maternity leave is ‘a time of preparation and planning ahead’ followed by a period when ‘lightening strikes on rejoining the workforce’ and ‘weathering the storm’ via an attempt to balance work and family life. Conclusion: Findings showed that while society encourages mothers to return to work after the birth of their children, few attempts have actually been made to support them during this delicate transition. This study identified the need to improve local policy with regards to family-friendly measures and the importance of an increase in local maternity leave duration. Moreover, the midwife was identified as an important figure that can help empower mothers and prepare them for what is yet to come.     

Emotions in labour: Italian obstetricians’ experiences of presence during childbirth

Objective: The present study represents a qualitative research aimed to explore the obstetricians’ psychological experiences of birth.

Background: During labour the role of obstetricians assumes a fundamental importance in hospitalised childbirth. However, literature analysis has shown that the psychological side of birth has been investigated only considering the woman’s and midwife’s points of view. The obstetricians’ psychological experiences have not been considered enough and only a few studies at a quantitative level have been performed.

Methods: Seven focus groups for a total of 72 obstetricians were conducted in hospital contexts in Italy. The qualitative methodology of grounded theory was adopted.

Findings: The results were divided into three different core themes: obstetricians’ approaches to delivery, critical aspects about relationships in the delivery room, and obstetricians’ feelings and emotions in the delivery room. Each theme was subdivided into different subthemes.

Conclusion: The results highlight different ways obstetricians approach their profession, the complex and multifaceted relationship with the woman and the extraordinary variety of feelings and emotions, which enrich, but also may complicate, life in the delivery room. Further studies could provide more details to help researchers to develop new and more effective strategies to support obstetricians’ training and work.     

Midwives’ personal experiences of pregnancy and childbirth: Exploring issues of autonomy and agency in relation to the use of professional knowledge

Abstract

This paper seeks to explore midwives’ experiences of pregnancy and childbirth. It draws on interviews with nine midwives who completed their midwifery training prior to becoming mothers, to discuss how midwives use their professional knowledge to exercise agency (the choices made about their own care), and assume autonomy (the control and responsibility in relation to their own care), in pregnancy and childbirth. It illustrates that a reliance on professional knowledge may create opportunities for choice and increased autonomy in some situations, although the need for intervention during childbirth, for example, may challenge the degree of autonomy exercised by midwives and the choices available to them. As knowledgeable experts, midwives demonstrate a very different understanding of risk and safety in relation to their own experiences of childbirth. Professional knowledge may increase their anxieties which may not be addressed appropriately by caregivers due to their professional status. The use of knowledge in this way highlights potential conflict between their position as midwives and their experience as mothers, illustrating that midwives’ ability to exercise agency and autonomy in relation to their pregnancy and childbirth experiences is potentially problematic.     

Termination of pregnancy for fetal abnormality: a meta-ethnography of women’s experiences

Due to technological advances in antenatal diagnosis of fetal abnormalities, more women face the prospect of terminating pregnancies on these grounds. Much existing research focuses on women’s psychological adaptation to this event. However, there is a lack of holistic understanding of women’s experiences. This article reports a systematic review of qualitative studies into women’s experiences of pregnancy termination for fetal abnormality. Eight databases were searched up to April 2014 for peer-reviewed studies, written in English, that reported primary or secondary data, used identifiable and interpretative qualitative methods, and offered a valuable contribution to the synthesis. Altogether, 4,281 records were screened; 14 met the inclusion criteria. The data were synthesised using meta-ethnography. Four themes were identified: a shattered world, losing and regaining control, the role of health professionals and the power of cultures. Pregnancy termination for fetal abnormality can be considered as a traumatic event that women experience as individuals, in their contact with the health professional community, and in the context of their politico-socio-legal environment. The range of emotions and experiences that pregnancy termination for fetal abnormality generates goes beyond the abortion paradigm and encompasses a bereavement model. Coordinated care pathways are needed that enable women to make their own decisions and receive supportive care.     

From the hospital organisation to the childbirth practice: Italian women’s experiences

Objective: To compare the hospital management of childbirth with respect to women’s perception and satisfaction. Method: Semi-structured interviews were conducted with 20 first-time Italian mothers, who were recruited in the obstetrics and gynaecology operative unit of a large public hospital in Northern Italy during the 3 days following the births of their children. Data were electronically coded with ATLAS.ti software and a qualitative analysis was conducted. Women’s childbirth narrations were compared with the formal procedures stated in the corporate documents of the hospital. Results: Expectations, control-medicalisation, and the relationship with the caregivers were the main themes that emerged from the interviews. The women’s expectations were related to the hospital’s reputation, which centred on medical specialisation and humanisation. Their actual experiences were characterised by their trust for hospital staff and willingness to give up internal control in order to accept medical interventions. These factors were related to the external control that the women accepted in order to preserve their child’s and their own safety. Although the hospital organisational model was centred on the humanisation of care and patient-centred service, these directives did not correspond to the women’s actual experiences. Conclusions: Health services should take into account the consumers’ perspective and address personal agency in order to increase satisfaction and guarantee a more respectful childbirth care.     

Puerperal psychosis – a qualitative study of women’s experiences

Objective: This study explored women’s experience of puerperal psychosis (PP) and their perceptions of its cause, in order to contribute to an increased understanding of PP and promote consideration of new management perspectives. Background: Out of every 1000 live births, approximately one to two women will develop PP. The numbers are relatively small, yet the consequences can be devastating. Key theoretical explanations for the aetiology of PP are genetic, biochemical and endocrine. A small and relatively tenuous evidence base considers PP from a psychological perspective, despite acknowledgement of the need for broader understanding. A stress–vulnerability model has offered a contemporary explanation of psychotic symptoms in other contexts and non-clinical populations and may offer useful insight in relation to a psychobiological model of PP. Methods: In a qualitative study, seven women who had been diagnosed with PP previously were interviewed and the data subjected to an inductive thematic analysis. Trustworthiness and rigour of the study was assured by careful monitoring of the research process and data checking. Results: Four themes were identified – The path to PP; Unspeakable thoughts and unacceptable self; ‘Snap out of it’; and Perceived causes. While women attributed their PP to the physiological changes associated with childbirth, their accounts of PP began before and during pregnancy. Women highlighted stressful pregnancies characterised by significant challenges and emotions, difficult births and unsupportive family relationships postnatally. The experience of PP was extremely distressing. Conclusion: Findings add to the debate about a more multifaceted explanation of PP and potentially offer a psychobiological model of understanding.     

Women’s experiences of routine care during labour and childbirth and the influence of medicalisation: A qualitative study from Iran

Objectiveto understand women’s experiences of routine care during labor and childbirth in a medicalised context.Designtwenty-six in-depth interviews were conducted during the late postpartum period and thematic analysis was applied.Settingfour public hospitals in Tehran with a high rate of births, providing services to low and middle income families.Participantswomen who had a low risk pregnancies and gave a birth to a healthy infant by normal vaginal delivery.Findingstwo main themes emerged: ‘An ethos of medicalisation’ which indicates that women’s perception of childbirth was influenced by the medicalised context of childbirth. And ‘The reality of fostered medicalisation’ which illustrates the process by which interventions during labor affected women’s pathway through childbirth, and how the medicalisation resulted in a birth experience which often included a preference for Caesarean Section rather than vaginal birth with multiple interventions.Implications for practicecontextual factors such as legal issues, state’s regulations and the organisational framework of maternity services foster medicalised childbirth in Tehran public hospitals. These factors influence the quality of care and should be considered in any intervention for change. The aim should be a high quality birth experience with minimal interventions during normal vaginal delivery. A midwifery model of care combining scientific evidence with empathy may address this need for change.     

Panamanian women׳s experience of vaginal examination in labour: A questionnaire validation

Aimto validate a tool that allows healthcare providers to obtain accurate information regarding Panamanian women׳s thoughts and feelings about vaginal examination during labour that can be used in other Latin-American countries.Methodsvalidation study based on a database from a cross-sectional study carried out in two tertiary care hospitals in Panama City, Panama. Women in the immediate postpartum period who had spontaneous labour onset and uncomplicated deliveries were included in the study from April to August 2008. Researchers used a survey designed by Lewin et al. that included 20 questions related to a patient׳s experience during a vaginal examination.Findingsfive constructs (factors) related to a patient׳s experience of vaginal examination during labour were identified: Approval (Alpha Cronbach׳s 0.72), Perception (0.67), Rejection (0.40), Consent (0.51), and Stress (0.20).Conclusionit was demonstrated the validity of the scale and its constructs used to obtain information related to vaginal examination during labour, including patients’ experiences with examination and healthcare staff performance.Implications for practiceutilisation of the scale will allow institutions to identify items that need improvement and address these areas in order to promote the best care for patients in labour.     

Assessing women’s perinatal psychological health: exploring the experiences of health visitors

Objective: This study aimed to explore health visitors’ (HVs) experiences of the assessment of women with psychological distress and mental health problems across the perinatal period in clinical practice. Background: In international contexts, there is now a firm policy remit for the assessment of psychological and mental health disorder across the perinatal period. Women are in regular contact with health professionals across this time and consultations intuitively create an ideal and appropriate context in which to assess women’s psychological health. National reports and academic literature highlight that to prevent the escalation of perinatal mental illness, significant change is needed to support health professionals in detecting, discussing and dealing with mental illnesses. Methods: In a qualitative aspect of a larger mixed-method study, data were collected from two Focus Group Discussions with HVs pre and post a training session related to assessing and managing perinatal mental health problems in practice. For the purposes of this paper, the data were explicitly examined for references to recognition and assessment. Results: Four themes emerged from the data: recognising the problem; questioning and identification; so what do I do now; the importance of support to promote effective identification and assessment. Conclusion: Findings elucidate the complexities that practitioners face in assessing women’s psychological health in real world settings. HVs’ experiences highlight that the implementation of measures into practice needs to be workable and accompanied by contemporary and appropriately contextualised knowledge, adequate service provision and clear referral pathways to ensure effective assessment of women’s psychological health.     

Active management of third stage of labour: a survey of providers’ knowledge in southwest Nigeria

Background  

The disparity between current evidence and practice on active management of third stage of labour (AMTSL) demands assessment of providers’ knowledge on the subject.     

Calculation of optimal gestation weight gain in pre-pregnancy underweight women due to body mass index change in relation to mother’s height

Background

Optimal gestational weight gain has not yet been clearly defined and remains one of the most controversial issues in modern perinatology. The role of optimal weight gain during pregnancy is critical, as it has a strong effect on perinatal outcomes.

Purpose

In this study, gestational body mass index (BMI) change, accounting for maternal height, was investigated as a new criterion for gestational weight gain determination, in the context of fetal growth assessment. We had focused on underweight women only, and aimed to assess whether the Institute of Medicine (IOM) guidelines could be considered acceptable or additional corrections are required in this subgroup of women.

Methods

The study included 1205 pre-pregnancy underweight mothers and their neonates. Only mothers with singleton term pregnancies (37th–42nd week of gestation) with pre-gestational BMI < 18.5 kg/m² were enrolled.

Results

The share of small for gestational age (SGA) infants in the study population was 16.2 %. Our results showed the minimal recommended gestational weight gain of 12–14 kg and BMI change of 4–5 kg/m² to be associated with a lower prevalence of SGA newborns. Based on our results, the recommended upper limit of gestational mass change could definitely be substantially higher.

Conclusion

Optimal weight gain in underweight women could be estimated in the very beginning of pregnancy as recommended BMI change, but recalculated in kilograms according to body height, which modulates the numerical calculation of BMI. Our proposal presents a further step forward towards individualized approach for each pregnant woman.

     

‘No more strangers’: Investigating the experiences of women,midwives and others during the establishment of a new model of maternity care for remote dwelling aboriginal women in northern Australia

Objectiveto describe the experiences of women, midwives and others during the establishment of a new model of maternity care for remote dwelling Aboriginal women transferred to a regional centre in northern Australia for maternity care and birth.Designa mixed method design within a Participatory Action Research approach was used. Qualitative findings are presented here. Data for this paper were collected from semi-structured interviews, field notes and observations and analysed thematically.Settingthe ‘top end’ of the Northern Territory of Australia.Participantsa total of 66 participants included six MGP midwives, two Aboriginal Health Workers and one Senior Aboriginal Woman working in the new model; eight hospital midwives; 34 Department of Health staff, three staff from other agencies; and 12 remote dwelling Aboriginal women who used the service.Findingsthe study generated one overarching theme, it's not a perfect system but it's changing. This encompassed improvements to the services evident to all participants. Core themes related to the previous maternity service which was described as the arduous journey, the new model was seen as a new way of working and a resultant very different journey occurred for Aboriginal women using the service.Key conclusions and implications for practicethere was a dissonance between the previous culture of maternity services and the woman centred focus of the new model. Over 12 months initial resistance to the new model diminished and it became highly valued. The transfer of information between the regional service and remote community health centres improved as did the safety and quality of care. Aboriginal women can access continuity of carer in the regional centre for the first time and reported a more positive experience with maternity services. The new model appears to have changed the cultural responsiveness of the regional maternity service; and care provided for remote dwelling women within this service. The qualitative findings inform others seeking to implement a similar model of care for remote dwelling women transferred to a regional centre for birth.