The relationship between women-centred care and women's birth experiences: a comparison between birth centres, clinics, and hospitals in Japan

Objective

the goal of women-centred care (WCC) is respect, safety, holism, partnership and the general well-being of women, which could lead to women's empowerment. The first step in providing WCC to all pregnant women is to describe women's perceptions of WCC during pregnancy in different health facilities. The objectives of this study were to ask (a) what are the perceptions and comparison of WCC at Japanese birth centres, clinics, and hospitals and (b) what are the relationships between WCC and three dimensions of women's birth experience: (1) satisfaction with care they received during pregnancy and birth, (2) sense of control during labour and birth, and (3) attachment to their new born babies.

Design

this was a cross-sectional study using self-completed retrospective questionnaires.

Setting

three types of health facility: birth centres (n=7), clinics (n=4), and hospitals (n=2).

Participants

participants were women who had a singleton birth and were admitted to one of the study settings. Women who were seriously ill were excluded. Data were analysed on 482 women.

Measurements

instrumentation included: a researcher-developed WCC-pregnancy questionnaire, Labour Agentry Scale, Maternal Attachment Questionnaire, and a researcher-developed Care Satisfaction Scale.

Findings

among the three types of settings, women who delivered at birth centres rated WCC highly and were satisfied with care they received compared to those who gave birth at clinics and hospitals. WCC was positively associated with women's satisfaction with the care they received.

Key conclusions

women giving birth at birth centres had the most positive perceptions of WCC. This was related to the respectful communication during antenatal checkups and the continuity of care by midwives, which were the core elements of WCC.

Implications for practice

health-care providers should consider the positive correlation of WCC and women's perception of satisfaction. Every woman should be provided continuity of care with respectful communication, which is a core element of WCC.     

The development and peer review of evidence-based guidelines to support midwifery led care in labour

Objective

to describe the development and peer review process for the third edition of evidence-based guidelines to support the provision of midwifery led care in labour.

Methods

the process of guideline development including identifying aspects of care for inclusion in the guidelines, the literature search strategy, bibliographic databases used, types of literature reviewed and rationale for inclusion are detailed. The process of formulating recommendations for practice is described. The peer review process, involving the principal stakeholders in the guidelines (midwives and representatives of maternity service users), the appraisal instrument used and issues identified during peer review are included. The third edition of the guidelines was commissioned in 2003 and completed during 2004.

Discussion

the development of the evidence-based guidelines is discussed in the context of contemporary debate related to guideline development and evidence-based practice including issues related to the nature and hierarchy of evidence, stakeholder involvement and sociological discourses of evidence-based medicine.     

The hardware and software implications of hospital birth room design: A midwifery perspective

Objective

to explore the impacts of physical and aesthetic design of hospital birth rooms on midwives.

Background

the design of a workplace, including architecture, equipment, furnishings and aesthetics, can influence the experience and performance of staff. Some research has explored the effects of workplace design in health care environments but very little research has examined the impact of design on midwives working in hospital birth rooms.

Methods

a video ethnographic study was undertaken and the labours of six women cared for by midwives were filmed. Filming took place in one birth centre and two labour wards within two Australian hospitals. Subsequently, eight midwives participated in video-reflexive interviews whilst viewing the filmed labour of the woman for whom they provided care. Thematic analysis of the midwife interviews was undertaken.

Findings

midwives were strongly affected by the design of the birth room. Four major themes were identified: finding a space amongst congestion and clutter; trying to work underwater; creating ambience in a clinical space and being equipped for flexible practice. Aesthetic features, room layout and the design of equipment and fixtures all impacted on the midwives and their practice in both birth centre and labour ward settings.

Conclusion and implications for practice

the current design of many hospital birth rooms challenges the provision of effective midwifery practice. Changes to the design and aesthetics of the hospital birth room may engender safer, more comfortable and more effective midwifery practice.     

Labour augmentation and fetal outcomes in relation to birth positions: A secondary analysis of an RCT evaluating birth seat births

Objective

the aim of this study was to compare the use of synthetic oxytocin for augmentation, duration of labour and birth and infant outcomes in nulliparous women randomised to birth on a birth seat or any other position.

Study design

a randomised controlled trial in Sweden where 1002 women were randomised to birth on a birth seat (experimental group) or birth in any other position (control group). Data were collected between November 2006 and July 2009. The outcome measurements included synthetic oxytocin augmentation, duration of the second stage of labour and fetal outcome. Analysis was by intention to treat.

Setting

southern Sweden.

Findings

the main findings of this study were that women randomised to the experimental group had a statistically significant shorter second stage of labour than women randomised to the control group. There were no differences between the groups for use of synthetic oxytocin augmentation or for neonatal outcomes.

Conclusions

women allocated to the birth seat had a significantly shorter second stage of labour despite similar numbers of women subjected to synthetic oxytocin augmentation in the study groups. The adverse neonatal outcomes did not differ between groups. The birth seat can be suggested as non-medical intervention used to reduce duration of second stage labour and birth. The birth seat can be suggested as a non-medical intervention that may facilitate reduced duration of the second stage of labour. Furthermore it is recommended that caregivers, both midwives and midwifery students, should learn skills to assist women in using a variety of birth positions.

Trial registration

unique Protocol ID: Dnr 2009/739 (register.clinicaltrials.gov).     

The relationship between the use of the partograph and birth outcomes at Korle-Bu teaching hospital

Objective

maternal mortality represents the single greatest health disparity between high and low income countries. This inequity is especially felt in low income countries in sub Saharan Africa and Southeast Asia where 99% of the global burden of maternal death is borne. A goal of MDG 5 is to reduce maternal mortality and have a skilled attendant at every birth by 2015. A critical skill is ongoing intrapartum monitoring of labour progress and maternal/fetal well-being. The WHO partograph was designed to assess these parameters.

Design and setting

a retrospective review of charts (n=1,845) retrieved consecutively over a 2 month period in a tertiary teaching hospital in Ghana was conducted to assess the adequacy of partograph use by skilled birth attendants and the timeliness of action taken if the action line was crossed. WHO guidelines were implemented to assess the adequacy of partograph use and how this affected maternal neonatal outcomes. Further, the timeliness and type of action taken if action line was crossed was assessed.

Findings

partographs were adequately completed in accordance with WHO guidelines only 25.6% (472) of the time and some data appeared to be entered retrospectively. Partograph use was associated with less maternal blood loss and neonatal injuries. When the action line was crossed (464), timely action was taken only 48.7% of the time and was associated with less assisted delivery and a fewer low Apgar scores and NICU admissions.

Conclusion

when adequately used and timely interventions taken, the partograph was an effective tool. Feasibility of partograph use requires more scrutiny; particularly identification of minimum frequency for safe monitoring and key variables as well as a better understanding of why skilled attendants have not consistently ‘bought in’ to partograph use. Frontline workers need access to ongoing and current education and strategically placed algorhythims.     

Epidural analgesia: breast-feeding success and related factors

Objective

to compare the early breast-feeding behaviours of full-term newborns whose mothers had received epidural analgesia (EDA) during an uncomplicated labour, with a group of newborns whose mothers had not received EDA.

Design and setting

a retrospective comparative study design was used and the study was carried out in a labour ward in Stockholm, Sweden between January 2000 and April 2000. The ward has about 5500 deliveries per year.

Participants

all maternity records of women who had received EDA during labour (n=585) were included in the study. For each EDA record, a control record was selected, matched for parity, age and gestational age at birth. Women with emergency caesarean section, vacuum extraction/forceps, twin pregnancy, breech presentation or an intra-uterine death, as well as neonates with an Apgar score <7 at 5 mins were excluded. After exclusion, the study population consisted of 351 healthy women and babies in each group.

Method

logistic regression was performed. The dependent variables: (1) initiation of breast feeding after birth; (2) artificial milk given during hospital stay; and (3) breast feeding at discharge were studied in response to: (a) parity; (b) gestational age at birth; (c) length of first and second stage of labour; (d) administration of oxytocin; (e) administration of EDA; and (f) neonatal weight, as independent variables.

Findings

significantly fewer babies of mothers with EDA during labour suckled the breast within the first 4 hours of life [odds ratio (OR) 3.79]. These babies were also more often given artificial milk during their hospital stay (OR 2.19) and fewer were fully breast fed at discharge (OR 1.79). Delayed initiation of breast feeding was also associated with a prolonged first (OR 2.81) and second stage (OR 2.49) and with the administration of oxytocin (OR 3.28). Fewer newborns of multiparae received artificial milk during their hospital stay (OR 0.58). It was also, but to a lesser extent, associated with oxytocin administration (OR 2.15). Full breast feeding at discharge was also positively associated with multiparity (OR 0.44) and birth weight between 3 and 4 kg (OR 0.42).

Key conclusions

the study shows that EDA is associated with impaired spontaneous breast feeding including breast feeding at discharge from the hospital. Further studies are needed on the effects of EDA on short- and long-term breast-feeding outcomes.     

Women's experiences of labour and birth: an evolutionary concept analysis

Aim

the aim of this paper is to identify the core attributes of the experience of labour and birth.

Methods

a literature search was conducted using a variety of online databases for the years 1990–2005. A thematic analysis of a random sample of 62 of these papers identified the main characteristics of the experience of childbirth. There are multiple methodological challenges in researching the experience of labour and birth, and in developing the existing complexity of evidence.

Results

despite agreement across disciplines regarding the significance of the childbirth experience, there is little consensus on a conceptual definition. Four main attributes of the experience were described as individual, complex, process and life event. Through this concept analysis, the experiences of labour and birth is defined as an individual life event, incorporating interrelated subjective psychological and physiological processes, influenced by social, environmental, organisational and policy contexts.

Conclusions

identification of the core attributes of the labour and birth experience may provide a framework for future consideration and investigation including further analysis of related concepts such as 'support' and 'control'.

Implications for practice

practitioners and researchers have already identified the diversity and complexity of women's experiences during labour and birth. The importance of the identified attributes also requires organisational and policy development within the context of a cultural environment that acknowledges this diversity.     

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.     

Management of third stage labour following vaginal birth in Iran: A survey of current policies

Objective

this study was aimed to provide information on policies for the practice of managing the third stage of labour in Iran, including discussion of related systematic evidence.

Design

this survey used a standard questionnaire to obtain information about prevention and early treatment of postpartum haemorrhage from all geographical areas in Iran, in 2010.

Setting

the survey included maternity units from 23 provinces, covering 129 out of a total of 560 maternity units in Iran.

Participants

at least one public hospital, one private hospital and one rural birth facility unit were included from each province. Questionnaires were completed by the unit's senior midwife with support from the unit's lead obstetrician.

Findings

all the units who were approached responded to the study including 69 public hospitals, 32 private hospitals and 28 rural birth facility units. The rate of active management of the third stage of labour was 57 per cent, although answers to individual components of management indicated a higher rate for active interventions than expectant management. Ninety-four per cent of the responding centres indicated oxytocin administration, 71 per cent apply early cord clamping and 65 per cent apply controlled cord traction. A lack of standard definition for postpartum haemorrhage was reported in 18 per cent of units.

Key conclusions

a high rate of active management was reported in Iran with variation in its different components which is in line with the international findings. These policies were mainly congruent with the existing systematic evidence except for timing of cord clamping.

Implications for practice

there is a need for improvement in locally sensitive policy development, continuing education, establishing accurate auditing systems and ensuring access to facilities such as blood banks and products in rural units. Efforts to reduce maternal mortality and morbidity and investigations into their causes should be extended to factors beyond the third stage of labour care clinical components.     

The relationship between prenatal control, expectations, experienced control, and birth satisfaction among primiparous women

Objectives

this paper explores the relationship between perceptions of prenatal control, expectations for childbirth, and experienced control in labour and birth and how they individually and collectively affect birth satisfaction.

Design

a repeated measures exploratory study was conducted with 31 primiparous women between 26 and 40 weeks pregnant. Standardised interviews were conducted prior to birth to assess levels of prenatal control and expectations for control during childbirth. Six weeks after the birth, women were interviewed again to assess experiences of control and birth satisfaction.

Setting

prenatal clinic, North Carolina, USA.

Findings

results show experienced control to be a significant predictor of birth satisfaction, with high levels of control correlating with high satisfaction levels. However, no correlations were found between the three aspects of control, and both prenatal control and birth expectations were found to have no significant effect on birth satisfaction. Findings also indicate that women cared for by midwives have significantly higher experienced control and birth satisfaction than women whose care was provided by obstetricians, while incidence of caesarean birth did not affect either measure.

Conclusions

experienced control during labour and birth is an important predictor of birth satisfaction. Health care providers should collaborate with the women they care for to use techniques that maximize the experience of control especially during labour and birth.     

‘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.     

Measuring the quality of documented care given by Swedish midwives during birth

Objectives

to measure the extent to which documented Swedish midwifery care for low-risk labour and birth followed the World Health Organization's (WHO) recommendations for care in normal birth, and to compare midwifery care given to women who’s labours were classified as low and high risk.

Study design

a retrospective examination of midwifery and medical records, 144 from women with low-risk births and 54 from women with high-risk births, for aspects of pregnancy, labour and birth using a validated instrument based on WHO’s recommendations.

Setting

southern Sweden.

Outcome measurements

care given in accordance with WHO’s four categories of practice and changes in risk group during the birth process.

Findings

care interventions not recommended by WHO, such as routine establishment of an intravenous route, routine amniotomy during the first stage, continuous electronic fetal monitoring and pharmacological methods of pain relief, were widespread in the records. Documented care differed little between the labours of women at low risk and high risk. The midwives at the unit under study did not routinely carry out risk assessment.

Key conclusions and implications for practice

the mode of care was one of readiness for medical intervention. The act of carrying out risk assessments at the time of the woman’s admission may affect awareness of the level of care offered to birthing women, and thus help to reduce the number and variety of practices not recommended by WHO.     

Determinants of place of birth decisions in uncomplicated childbirth in Bangladesh: An empirical study

Objective

to test the predictive value of women's self-identified criteria in place of birth decisions in the event of uncomplicated childbirth in a setting where facility based skilled birth attendants are available.

Design

a retrospective, cross-sectional study was conducted in two phases. The first phase used data from in-depth interviews. The second phase used data from semi-structured questionnaires.

Setting

the service area of Matlab, Bangladesh.

Participants

women 18–49 years who had an uncomplicated pregnancy and delivery resulting in a live birth.

Findings

a women's intention about where to deliver during pregnancy, her perception of labour progress, the availability of transportation at the time of labour, and the close proximity of a dai to the household were independent predictors of facility-based SBA use. Marital age was also significant predictor of use.

Key conclusions

the availability of delivery services does not guarantee use and instead specific considerations and conditions during pregnancy and in and around the time of birth influence the preventive health seeking behaviour of women during childbirth. Our findings have implications for birth preparedness and complication readiness initiatives that aim to strengthen timely use of SBAs for all births. Demand side strategies to reduce barriers to health seeking, as part of an overall health system strengthening approach, are needed to meet the Millennium Development 5 goal.     

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.