A hero's tale of childbirth

Objectives

to present a secondary analysis of the findings from an interpretive phenomenological study of women who had experienced a self-defined traumatic and subsequent positive birth experience.

Design

a re-interpretation of women's accounts through the conceptual lens of the hero narrative framework developed by Campbell (1993).

Setting

12 women recruited from a large maternity trust in North-West England.

Findings

by drawing upon Campbell's analysis of myth and folklore, contextualised by the women's narratives, we illuminate the adversity and dysphoria of a distressing birth, and how through taking courage, drawing on inner strength and accessing targeted support, all of the participants went on to achieve a joyful, healing birth experience. This analysis reveals the power, courage and determination of the childbearing women in this study, and to re-envision their journey as a ‘hero's tale’.

Conclusion

this paper uncovers how myth can illuminate existential accounts of a phenomenon as well as raise important practice based implications. Creating services based on these principles has the potential to translate the theoretical insights from this study into a new maternity care praxis.     

‘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.     

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.     

Enhancing early postnatal care: findings from a major reform of maternity care in three Australian hospitals

Background

four hospitals comprising a health network in Melbourne, Australia, implemented a range of initiatives aimed at enhancing women's experiences of postnatal maternity care.

Objective

to compare women's views and experiences of early postnatal care before and after implementation of maternity enhancement initiatives.

Design

‘before and after’ study design incorporating two postal surveys of recent mothers (baseline and post-implementation).

Setting

four hospitals in Melbourne, Australia. Analysis of postnatal outcomes was confined to three hospitals where the initiatives were fully operational.

Participants

1256 women participated in the baseline survey in 1999 (before implementing the initiative) and 1050 women responded to the post-implementation survey in 2001.

Findings

the response to the 1999 baseline survey was 65.3% (1256/1922) and to the 2001 post-implementation survey 57.4% (1050/1829). Comparative analysis revealed a statistically significant improvement in overall ratings of hospital postnatal care; the level of advice and support received in relation to discharge and going home; the sensitivity of caregivers; and the proportion of women receiving domiciliary care after discharge. There was little change in the time women spent in hospital after birth between the two survey time-points. Over 90% of women reported one or more health problems in the first 3 months postpartum. The proportion of women reporting physical or emotional health problems between the two surveys did not change.

Key conclusion

mainstream maternity care can be restructured to improve women's experiences of early postnatal care.

Implications for practice

maternity service providers should consider a multi-faceted approach to reorientating postnatal services and improving women's experiences of care. Approaches worthy of consideration include attempts to ensure consistency and continuity of care through staffing arrangements, guidelines and protocols; an emphasis on planning for postnatal care during pregnancy; the use of evidence to inform both consumer information and advice and in the practice of caring; and skill-enhancement opportunities for care providers in managing postnatal issues and in effective communication.     

‘Every pregnant woman needs a midwife’—The experiences of HIV affected women in maternity care

Title

‘Every pregnant woman needs a midwife’—the experiences of HIV affected women in Northern Ireland.

Objective

to explore HIV positive women's experiences of pregnancy and maternity care, with a focus on their interactions with midwives.

Design

a prospective qualitative study.

Setting

regional HIV unit in Northern Ireland.

Participants

22 interviews were conducted with 10 women at different stages of their reproductive trajectories.

Findings

the pervasive presence of HIV related stigma threatened the women's experience of pregnancy and care. The key staff attributes that facilitated a positive experience were knowledge and experience, empathy and understanding of their unique needs and continuity of care.

Key conclusions

pregnancy in the context of HIV, whilst offering a much needed sense of normality, also increases woman's sense of anxiety and vulnerability and therefore the need for supportive interventions that affirm normality is intensified. A maternity team approach, with a focus on providing ‘balanced care’ could meet all of the woman and child's medical needs, whilst also emphasising the normalcy of pregnancy.     

‘My pain was stronger than my happiness’: Experiences of caesarean births from Lebanon

Objective

the rising trends in caesarean section have been partially attributed to women's requests. Many studies in developed and very few in developing countries have attempted to understand this phenomenon. This qualitative study explores experiences of women having caesarean section on demand in a middle-income country with a private health-care system.

Design

an inductive qualitative design, using face-to-face semi-structured interviews.

Setting

women were identified and recruited through a perinatal database and selected obstetricians' clinics in the Greater Beirut area in Lebanon.

Participants

a purposive sample of women who had a caesarean childbirth within the four months preceding the interview, were visited for an interview at home using a semi-structured interview guide. Thematic content analysis was conducted on a sub-sample of 22 women who requested a caesarean birth.

Findings

lack of information about caesarean sections fosters women's fear from labour pain and acts as the main impetus for women to consider caesareans as the pain free alternative. Findings reveal health-care providers' role in reinforcing beliefs about caesarean sections being the way for pain free deliveries by overestimating the safety of the procedure and disregarding postpartum health issues.

Key conclusion and implications for practice

caesarean birth is presented to women as a safe option for ‘pain free’ childbirth. This needs to be considered within the cultural context of understanding safety and pain as well as the dynamics of power in maternity care. Health-care professionals need to explore these dimensions and promote women's informed choice as well as encouraging the normality of birth.     

Childbirth traditions and cultural perceptions of safety in Nepal: Critical spaces to ensure the survival of mothers and newborns in remote mountain villages

Objective

to uncover local beliefs regarding pregnancy and birth in remote mountainous villages of Nepal in order to understand the factors which impact on women's experiences of pregnancy and childbirth and the related interplay of tradition, spiritual beliefs, risk and safety which impact on those experiences.

Design

this study used a qualitative methodological approach with in-depth interviews framework within social constructionist and feminist critical theories.

Setting

the setting comprised two remote Nepalese mountain villages where women have high rates of illiteracy, poverty, disadvantage, maternal and newborn mortality, and low life expectancy. Interviews were conducted between February and June, 2010.

Participants

twenty five pregnant/postnatal women, five husbands, five mothers-in-law, one father-in-law, five service providers and five community stakeholders from the local communities were involved.

Findings

Nepalese women, their families and most of their community strongly value their childbirth traditions and associated spiritual beliefs and they profoundly shape women's views of safety and risk during pregnancy and childbirth, influencing how birth and new motherhood fit into daily life. These intense culturally-based views of childbirth safety and risk conflict starkly with the medical view of childbirth safety and risk.

Key conclusions and implications for practice

if maternity services are to improve maternal and neonatal survival rates in Nepal, maternity care providers must genuinely partner with local women inclusive of their cultural beliefs, and provide locally based primary maternity care. Women will then be more likely to attend maternity care services, and benefit from feeling culturally safe and culturally respected within their spiritual traditions of birth supported by the reduction of risk provided by informed and reverent medicalised care.     

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.     

Womens' attitudes and beliefs of childbirth and association with birth preference: A comparison of a Swedish and an Australian sample in mid-pregnancy

Background

the rate of caesarean in Australia is twice that of Sweden. Little is known about women's attitudes towards birth in countries where the caesarean rate is high compared to those where normal birth is a more common event.

Objectives

to compare attitudes and beliefs towards birth in a sample of Australian and Swedish women in mid-pregnancy.

Participants

women from rural towns in mid Sweden (n=386) and north-eastern Victoria in Australia (n=123).

Methods

questionnaire data was collected from 2007 to 2009. Levels of agreement or disagreement were indicated on sixteen attitude and belief statements regarding birth. Principal components analysis (PCA) identified the presence of subscales within the attitudes inventory. Using these subscales, attitudes associated with preferred mode of birth were determined. Odds ratios were calculated at 95% CI by country of care.

Results

the Australian sample was less likely than the Swedish sample to agree that they would like a birth that: ‘is as pain free as possible' OR 0.4 (95% CI: 0.2–0.7), ‘will reduce my chance of stress incontinence' OR 0.2 (95% CI: 0.1–0.8), ‘will least affect my future sex life' OR 0.3 (95% CI: 0.2–0.6), ‘will allow me to plan the date when my baby is born' OR 0.4 (95% CI: 0.2–0.7) and ‘is as natural as possible' OR 0.4 (95% CI: 0.2–0.9). They were also less likely to agree that: ‘if a woman wants to have a caesarean she should be able to have one under any circumstances’ OR 0.4 (95% CI: 0.2–0.7) and ‘giving birth is a natural process that should not be interfered with unless necessary’ OR 0.3 (95% CI: 0.1–0.7). Four attitudinal subscales were found: ‘Personal Impact of Birth', ‘Birth as Natural Event', ‘Freedom of Choice' and ‘Safety Concerns'. Women who preferred a caesarean, compared to those who preferred a vaginal birth, across both countries were less likely to think of ‘Birth as a natural event’.

Key conclusions

the Australian women were less likely than the Swedish women to hold attitudes and beliefs regarding the impact of pregnancy and birth on their body, the right to determine the type of birth they want and to value the natural process of birth. Women from both countries who preferred caesarean were less likely to agree with attitudes related to birth as a natural event.     

Swedish women's experiences of doula support during childbirth

Objective

to describe women's experiences of doula support during childbirth.

Design and setting

a qualitative study using a hermeneutic approach. Data were collected via tape-recorded interviews in the women's homes or at a place chosen by the women, one to eight months after the birth.

Participants

nine women, seven primiparous and two multiparous, aged between 15 and 40 years, who had received antenatal care at a special clinic for single mothers in Gothenburg, Sweden between 2006 and 2007.

Key findings

the role of the doula lies between natural care and professional care, veering towards professional care. Professional aspects include being a mediator to the unknown, and a human life line to help the woman to play her part in the birth. Furthermore, the doula is a coach who mediates a belief in the woman's capacity to give birth. The midwives’ supporting role is not clear to the women, which can be the result of doulas having a more professional supporting role than giving natural care. Midwives are unable to offer continuity of care and constant support during the birth.

Implications for practice

the different supporting roles of doulas and midwives in maternity care should be addressed. Furthermore, maternity care should be organised in a way that gives the woman an opportunity to access continuity of care and constant support.     

Organisational strategies and midwives' readiness to provide care for out of hospital births: An analysis from the Birthplace organisational case studies

Objective

the objective of the Birthplace in England Case Studies was to explore the organisational and professional issues that may impact on the quality and safety of labour and birth care in different birth settings: Home, Freestanding Midwifery Unit, Alongside Midwifery Unit or Obstetric Unit. This analysis examines the factors affecting the readiness of community midwives to provide women with choice of out of hospital birth, using the findings from the Birthplace in England Case Studies.

Design

organisational ethnographic case studies, including interviews with professionals, key stakeholders, women and partners, observations of service processes and document review.

Setting

a maximum variation sample of four maternity services in terms of configuration, region and population characteristics. All were selected from the Birthplace cohort study sample as services scoring ‘best’ or ‘better’ performing in the Health Care Commission survey of maternity services (HCC 2008).

Participants

professionals and stakeholders (n=86), women (64), partners (6), plus 50 observations and 200 service documents.

Findings

each service experienced challenges in providing an integrated service to support choice of place of birth. Deployment of community midwives was a particular concern. Community midwives and managers expressed lack of confidence in availability to cover home birth care in particular, with the exception of caseload midwifery and a ‘hub and spoke’ model of care. Community midwives and women's interviews indicated that many lacked home birth experience and confidence. Those in midwifery units expressed higher levels of support and confidence.

Key conclusions and implications for practice

maternity services need to consider and develop models for provision of a more integrated model of staffing across hospital and community boundaries.     

Why do women request caesarean section in a normal,healthy first pregnancy?

Background and context

a growing number of childbearing women are reported to prefer a caesarean section in the absence of a medical reason. Qualitative research describing factors influencing this preference in pregnant women is lacking.

Objective

to describe Australian women's request for caesarean section in the absence of medical indicators in their first pregnancy.

Design

advertisements were placed in local newspapers inviting women to participate in a telephone interview exploring women's experience of caesarean section. Thematic analysis was used to analyse data.

Setting

two states of Australia: Queensland and Western Australia.

Participants

a community sample of women (n=210) responded to the advertisements. This paper presents the findings elicited from interviews conducted with 14 women who requested a caesarean section during their first pregnancy in the absence of a known medical indication.

Findings

childbirth fear, issues of control and safety, and a devaluing of the female body and birth process were the main themes underpinning women's requests for a non-medically-indicated caesarean section. Women perceived that medical discourses supported and reinforced their decision as a ‘safe’ and ‘responsible’ choice.

Key conclusions and recommendations for practice

these findings assist women and health professionals to better understand how childbirth can be constructed as a fearful event. In light of the evidence about the risks associated with surgical birth, health-care professionals need to explore these perceptions with women and develop strategies to promote women's confidence and competence in their ability to give birth naturally.     

Childbirth in exile: Asylum seeking women's experience of childbirth in Ireland

Objectives

the purpose of this study was to gain insight into women's experiences of childbirth in Ireland while in the process of seeking asylum. This paper will focus on one of the primary findings of the study, how lack of connection, communication and cultural understanding impacted the health and well-being of the women who participated.

Design

researchers adopted a structural approach to narrative analysis using Burke's (1969) dramatistic pentad to analyse 22 women's narrative accounts of their childbirth experiences. Ethical approval was granted, and the study was funded by the Irish Health Research Board.

Findings

Burke's (1969) dramatistic pentad revealed numerous accounts of Scene/Agent and Act/Agency imbalance in the women's experiences, highlighting lack of communication, connection and culturally competent care evident in their experiences and how this impacted the care they received.

Conclusion

inadequate, poorly organised maternity services complicated by lack of training in cultural understanding and sporadic access to interpreter services had a detrimental impact on care provision. Providers appeared to have little insight into the specific needs of this vulnerable group already traumatised by pre and post migratory stressors. The resulting lack of effective connection and communication exacerbated women's experiences of alienation, loneliness, and isolation and were universal in the women's accounts. Implications for practice need to focus in Burkean terms on ‘How’ (Agency) providers can meet the maternity care needs of asylum seeking women. Dedicated community based services, mandatory training in cultural competence, 24 hour access to interpreters, information leaflets in several languages are essential measures. Further research looking specifically at the antenatal care and childbirth education needs of ethnic minority women is needed. Also, there is an urgent need for further exploration of the barriers to communication and the utilisation of trained interpreters in the provision of effective care to non-English speaking ethnic minority women.     

A non-randomised trial investigating the cost-effectiveness of Midwifery Group Practice compared with standard maternity care arrangements in one Australian hospital

Objective

to compare cost-effectiveness of two models of maternity service delivery: Midwifery Group Practice (MGP) at a birth centre and standard care (SC).

Design

a prospective non-randomised trial.

Setting

an Australian metropolitan hospital.

Method

women at 36 weeks gestation were approached in the birth centre or hospital antenatal clinics between March and December 2008. Of 170 consecutive women who met birth centre eligibility criteria, 70% (n=119) were recruited to the study. Women (MGP n=52 or standard care n=50) were followed through to 6 weeks postpartum. Publically funded care costs were collected from women's diaries, handheld pregnancy health records, medical records and the hospital accounting system. Main outcome measures: health-care costs to the hospital and government.

Analysis

generalised linear models with covariates of age, nulliparity, private health insurance (yes/no) and household income category.

Findings

women receiving MGP care were less likely to experience induction of labour, required fewer antenatal visits, received more postnatal care, and neonates were less likely to be admitted to special care nursery than those receiving standard care. Statistically significant lower costs were found for women and babies receiving MGP care compared with women receiving standard care during pregnancy, labour and birth and postpartum to 6 weeks. MGP resulted in lower costs for the hospital ($AUD4,696 vs. $AUD5,521 p<0.001) and the government ($AUD4,722 vs. $AUD5,641 p<0.001). When baby costs were excluded MGP care remained statistically significantly cheaper than standard care.

Conclusion

for women at low-risk of birth complications, Midwifery Group Practice was cost effective, and women experienced fewer obstetric interventions compared with standard maternity care. The evidence suggests Midwifery Group Practice is safe and economically viable.     

‘Off everyone's radar’: Australian women's experiences of medically necessary elective caesarean section

Introduction

despite an exponential rise in the number of medically initiated elective caesarean sections over the last two decades, women's experiences of this birth mode remain largely unknown. The aim of this study was to address this gap by describing women's experiences of medically necessary elective caesarean section.

Methods

a grounded theory approach was used to collect and analyse interview data collected from 28 Australian women who had an elective caesarean section for a medical reason, 14 of whom were also observed during their caesarean section. The analyses of the non-participant observations were used to contextualise the women's experiences.

Findings

prior to having their baby, women expected to play an active part in their caesarean section and to be supported to take up their ‘mother’ role as soon as their baby was delivered. Postnatally however, they reported having felt invisible, superfluous and disregarded during the event. There was evidence that hospital routines and processes contributed to women feeling displaced and unimportant in their baby's birth. Three sub-categories were formed from the analysis of the data that together are represented by the in-vivo label ‘off everyone's radar’. These were ‘just another case on an operating list’, ‘striving to be included while trying to behave’ and ‘unable to be my baby's mum’.

Discussion

our findings suggest that when women are ignored during childbirth, any fear they hold may escalate into peritraumatic disassociation, which in turn has implications for women's postnatal mental and emotional health in the short and long term. In addition, the separation of the mother–baby dyad was found to have a devastating impact on maternal–newborn attachment that lasted well into the postnatal period. To optimise women's childbirth satisfaction and foster their attachment to their baby, both of which are essential for ongoing emotional well-being, it is vital that they are located at the centre of their birth experience and that if at all possible they are not separated from their newborn.     

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.