The delivery room: Is it a safe place? A hermeneutic analysis of women's negative birth experiences

Association of childbirth experience with long-term psychological outcomes: a prospective cohort study

BACKGROUND

There has been limited research on the lasting impact of giving birth on both mothers and infants. This study aimed to investigate women's memories of their childbirth experience 4 months and 4 years after giving birth. Additionally, it aimed to examine how the childbirth experience is linked to women's mental health, sexual satisfaction, exclusive breastfeeding, and the type of subsequent birth.

METHODS

In this prospective cohort study, a total of 580 women giving birth in Tabriz hospitals in 2018 were followed up for 4 years. The data were collected using a childbirth experience questionnaire, a mental health inventory, and a sexual satisfaction scale for women, and were analyzed by a Pearson correlation test, an independent samples t-test, and a general linear model.

RESULTS

The total scores of the childbirth experience in two short-term (4 months) and long-term (4 years) time points following the birth had a significant and strong correlation with each other (r = .51; p < .001). After adjusting for the effects of socio-demographic and obstetric characteristics, sexual satisfaction had significant relationships with childbirth experience (p < .001) and postpartum complications (p < .001). In addition, mental health had significant relationships with childbirth experience (p < .001), postpartum complications (p < .001), and low income (p = .004).

CONCLUSIONS

Even 4 years after giving birth, women have a clear recall of their childbirth experience. This experience has a significant association with long-term outcomes such as sexual satisfaction, mental health, exclusive breastfeeding, and subsequent birth type.

Birth environment interventions and outcomes: A scoping review

BACKGROUND

The physical environments in which women give birth can contribute positively to meeting both physiologic and psychosocial needs during labor. Most studies on the labor and delivery processes have focused on mitigating pain and providing psychological support. Fewer have explored the influence of the physical birth environment. In this study, we performed a scoping review to compile and examine qualitative and quantitative studies related to the characteristics of physical birth environments and their effects on labor outcomes.

METHODS

We searched the PubMed, CINHAL, Cochrane, Web of Science, and MEDLINE databases from inception to May 2022. A total of 13 studies met the criteria for inclusion in our review. Two reviewers screened the titles and full-text articles and extracted data from the included studies. We used summary statistics and narrative summaries to describe the study characteristics, intervention implementation guidelines, intervention selection and tailoring rationale, and intervention effects.

RESULTS

In previous research, several elements of birth environments have been shown to provide physical and psychological support to birthing people and to improve outcomes related to the experience of care and pain management. We identified five main themes in the included studies: (1) "hominess;" (2) whether spaces are comfortable for activity; (3) demedicalization of the birth environment; (4) accommodations for birth partners; and (5) providing women with a sense of control over their birth environment.

CONCLUSIONS

Birth environments should be designed to promote positive birthing experiences, both physiologically and psychologically. Facilities and those who manage them can improve the experiences and outcomes of service users by modifying or designing spaces that are "homey," comfortable for activity, demedicalized, and include natural elements. In addition, policies that allow the birthing person to control her own environment are key to promoting positive outcomes and satisfaction with the birth experience.

Cultural adaptation and psychometric evaluation of Childbirth Experience Questionnaire 2 in Karnataka state, India

BACKGROUND

Women's birthing experience is a sensitive indicator of the quality of childbirth care and can impact the physical and mental health of both women and their neonates. Negligible evidence exists on Indian women's birth experiences and-to the best of authors' knowledge-no questionnaire has been tested in India for measuring women's birthing experiences. This study aimed to test the construct validity and reliability of the Kannada-translated Revised Childbirth Experience Questionnaire.

METHODOLOGY

A cross-sectional survey was carried out among postnatal women (n = 251, up to six months postpartum, with a live healthy neonate) who had given birth at a public or private health facility using the Kannada-translated CEQ2 in two districts of Karnataka. Data were collected at participants' homes after seeking written informed consent. Model fit was determined by Confirmatory Factor Analyses.

RESULTS

The 4-factor model of the CEQ2 showed good fit after deletion of one item (item 8, subcategory "participation") with CMIN = 1.33; SRMR = 0.04; GFI = 0.92, CFI = 0.98, TLI = 0.99, RMSEA = 0.037 and p value 0.002). The Cronbach alpha values were acceptable for the four subscales (0.92, 0.93, 0.97, 0.91) as well as for the overall 21-item scale (0.84).

CONCLUSIONS

The Kannada-translated CEQ2 is a reliable tool to measure the childbirth experiences among Kannada-speaking women and can serve as a reliable ongoing evaluation of women's birth experiences.

'Development and psychometric evaluation of the safety feeling scale in adult patients at hospital: Exploratory sequential mixed method'

AIM AND OBJECTIVES

This study aimed to develop and examine psychometric properties of the safety feeling scale (SFS) in adult patients to assess their sense of safety during a hospital stay.

DESIGN

Mixed methods design. A SQUIRE checklist was used.

METHODS

This is a study with two phases of scale development and evaluation of the psychometric properties of the scale. In the first phase, the concept of 'safety feeling' was analysed using a hybrid model. Thus, a systematic review and then a qualitative study with hospitalized patients (n = 31) were conducted by conventional content analysis. In the psychometric phase, factorial validity, reliability, feasibility, and responsiveness of the scale were evaluated by different tests in various samples.

RESULTS

After integrating the results of the systematic review and qualitative study, a scale item pool with 84 items was developed. In the psychometric phase, 12 items with four factors were specified; 'effective care,' 'confidence in the healthcare team,' 'emotional enrichment' and 'hygienic facilities,' explaining 51% of the total variance of the scale. They were confirmed by confirmatory factor analysis. Internal consistency and stability of the scale were satisfactory. Feasibility and responsiveness were also acceptable.

Swedish midwives' experiences of collegial midwifery assistance during the second stage of labour: A qualitative study

BACKGROUND

There has been an increased focus on clinical practice that may reduce severe perineal trauma due to awareness of the associated morbidity. Knowledge regarding the best practice to reduce these injuries is limited. Collegial midwifery assistance during the second stage of labour that involves an additional midwife being present has recently been implemented into many Swedish birth units with the aim of reducing severe perineal trauma. However, no studies have been conducted to evaluate midwives' experiences and views of this practice.

AIM

The aim of this study was to explore midwives' experiences of collegial midwifery assistance during the second stage of labour.

METHODS

A qualitative study was undertaken with five focus groups conducted with 37 midwives who were part of a multisite randomised controlled trial. The data was analysed with reflexive thematic analysis.

FINDINGS

Four key themes were generated: (i) "challenging the professional role"; (ii) "a balancing act between different roles"; (iii) "not just why and how - but who"; (iv) "a potential arena for learning".

CONCLUSION

This practice enabled valuable collegial support and learning. The midwives' experiences were multifaceted and influenced by several factors, including norms and culture in the birth units as well as personal relationships and the midwives' views on their role and childbirth. Staffing should be adapted in clinical practice to optimise the conditions for collegial support and learning while avoiding unintended consequences.

Developing a woman-centered, inclusive definition of traumatic childbirth experiences: A discussion paper

INTRODUCTION

Many women experience giving birth as traumatic. Although women's subjective experiences of trauma are considered the most important, currently there is no clear inclusive definition of a traumatic birth to help guide practice, education, and research.

AIM

To formulate a woman-centered, inclusive definition of a traumatic childbirth experience.

METHODS

After a rapid literature review, a five-step process was undertaken. First, a draft definition was created based on interdisciplinary experts' views. The definition was then discussed and reformulated with input from over 60 multidisciplinary clinicians and researchers during a perinatal mental health and birth trauma research meeting in Europe. A revised definition was then shared with consumer groups in eight countries to confirm its face validity and adjusted based on their feedback.

RESULTS

The stepwise process confirmed that a woman-centered and inclusive definition was important. The final definition was: "A traumatic childbirth experience refers to a woman's experience of interactions and/or events directly related to childbirth that caused overwhelming distressing emotions and reactions; leading to short and/ or long-term negative impacts on a woman's health and wellbeing."

CONCLUSIONS

This definition of a traumatic childbirth experience was developed through consultations with experts and consumer groups. The definition acknowledges that low-quality provider interactions and obstetric violence can traumatize individuals during childbirth. The women-centered and inclusive focus could help women to identify and validate their experiences of traumatic birth, offering benefits for practice, education, and research, as well as for policymaking and activism in the fields of perinatal mental health and respectful maternity care.

Developing a woman-centered, inclusive definition of positive childbirth experiences: A discussion paper

INTRODUCTION

A positive childbirth experience promotes women's health, both during and beyond the perinatal period. Understanding what constitutes a positive childbirth experience is thus critical to providing high-quality maternity care. Currently, there is no clear, inclusive, woman-centered definition of a positive childbirth experience to guide practice, education, and research.

AIM

To formulate an inclusive woman-centered definition of a positive childbirth experience.

METHODS

A six-step process was undertaken: (a) Key concepts associated with a positive childbirth were derived from a rapid literature review; (b) The key concepts were used by interdisciplinary experts in the author group to create a draft definition; (c) The draft definition was presented to clinicians and researchers during a European research meeting on perinatal mental health; (d) The authors integrated the expert feedback to refine the working definition; (e) A revised definition was shared with women from consumer groups in six countries to confirm its face validity; and (f) A final definition was formulated based on the women's feedback (n = 42).

RESULTS

The following definition was formulated: "A positive childbirth experience refers to a woman's experience of interactions and events directly related to childbirth that made her feel supported, in control, safe, and respected; a positive childbirth can make women feel joy, confident, and/or accomplished and may have short and/or long-term positive impacts on a woman's psychosocial well-being."

CONCLUSIONS

This inclusive, woman-centered definition highlights the importance of provider interactions for facilitating a positive childbirth experience. Feeling supported and having a sense of control, safety, and respect are central tenets. This definition could help to identify and validate positive childbirth experience(s), and to inform practice, education, research, advocacy, and policy-making.

'The System is Not Set up for the Benefit of Women': Women's Experiences of Decision-Making During Pregnancy and Birth in Ireland

In this article, I draw on in-depth qualitative interviews with 23 women, conducted in 2019/2020, focusing on their involvement in decision-making during pregnancy and birth. The study is located in Ireland, where comparably progressive national policies regarding informed choice in labour and birth clash with the day-to-day reality of a heavily medicalised, paternalistic maternity care system. I represent the subjective experiences of a diverse group of women through in-depth interview excerpts. In my analysis, I move beyond describing what is happening in the Irish maternity system to discussing why this is happening - relating the findings of the research to the international literature on authoritative knowledge, technocratic hospital cultures and risk-based discourses around birth. In the last section of the article, I offer concrete, empirically grounded and innovative recommendations how to enhance women's involvement in decision-making.

Policy, service, and training provision for women following a traumatic birth: an international knowledge mapping exercise

Background

High numbers of women experience a traumatic birth, which can lead to childbirth-related post-traumatic stress disorder (CB-PTSD) onset, and negative and pervasive impacts for women, infants, and families. Policies, suitable service provision, and training are needed to identify and treat psychological morbidity following a traumatic birth experience, but currently there is little insight into whether and what is provided in different contexts. The aim of this knowledge mapping exercise was to map policy, service and training provision for women following a traumatic birth experience in different European countries.

Methods

A survey was distributed as part of the COST Action “Perinatal mental health and birth-related trauma: Maximizing best practice and optimal outcomes”. Questions were designed to capture country level data; care provision (i.e., national policies or guidelines for the screening, treatment and/or prevention of a traumatic birth, service provision), and nationally mandated pre-registration and post-registration training for maternity professionals.

Results

Eighteen countries participated. Only one country (the Netherlands) had national policies regarding the screening, treatment, and prevention of a traumatic birth experience/CB-PTSD. Service provision was provided formally in six countries (33%), and informally in the majority (78%). In almost all countries (89%), women could be referred to specialist perinatal or mental health services. Services tended to be provided by midwives, although some multidisciplinary practice was apparent. Seven (39%) of the countries offered ‘a few hours’ professional/pre-registration training, but none offered nationally mandated post-registration training.

Conclusions

A traumatic birth experience is a key public health concern. Evidence highlights important gaps regarding formalized care provision and training for care providers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07238-x.

Health-seeking behaviour among pregnant women during the COVID-19 pandemic: A qualitative study

Background

The novel coronavirus pandemic has killed millions of people globally while significantly destroying the social, economic, and political wellbeing of people. The global pandemic has negatively impacted pregnant women's access to prenatal care. The current study sought to understand the health-seeking behaviour of women who were pregnant during the onset of the COVID-19 pandemic in Kenya.

Methods

The “Three Delay” model theoretical framework was applied to piece together the pregnant women's health-seeking behaviour during the early stages of the pandemic through focus group discussions. The collected qualitative data was analysed using thematic analysis.

Results

The delays in deciding to seek care, delays in reaching healthcare facilities and delays in receiving quality healthcare services at the healthcare facility were a result of the fear of contracting the virus. These delays were occasioned by participants’ personal experiences and uncertainties about COVID-19 pandemic, compulsory quarantines, national cessation of movements, compulsory lockdowns, loss of income to many households and the influence of traditional birth attendants (TBAs).

Conclusion

The current study found that fear of COVID-19 was a major factor that hindered access to maternal healthcare services. In this regard, there is a need to upscale awareness creation on the significance of seeking maternal health services during the pandemic to reduce the possibility of obliterating the gains made in reducing poor health-seeking behaviours among pregnant women.

Space and place for health and care

Purpose: This discussion paper aims to contribute to a greater understanding of the state of the art of research engaged with conceptual matters of space and place for health and care. Method: The authors, who represent a variety of academic disciplines, discuss and demonstrate the conceptual recognition of space and place in research in health and caring sciences building upon own work and experience. Results: To explore the concepts of space and place for health and care is a research pursuit of utmost importance, and should be made through transdisciplinary research collaborations, whereby spatial theories from various disciplines could be communicated to cultivate truly novel and well-informed research. Furthermore, engaging with relational and topological perceptions of space and place poses methodological challenges to overcome in future research on health and care. Conclusions: We argue that there is a need for accelerating spatially informed research on health and care that is informed by current theories and perspectives on space and place, and transdisciplinary research collaborations are a means to achieving this.

Place and space in relation to childbirth: a critical interpretive synthesis

Background: In nursing and midwifery, the concept of environment is considered a meta-concept. Research findings suggest that the location is not the only important factor, as both place and space influence the practices of midwives. Moreover, research on the geography of health suggests a connection between place and health that could be extended to reproductive health. Therefore, to move beyond and expand traditional research expressions, it is beneficial to illuminate the concepts of place and space in relation to childbirth. Purpose: This study was undertaken to produce a synthesis of previous qualitative research of issues in childbirth in relation to the concepts of place and space. Method: In this Critical Interpretive Synthesis (CIS), four electronic databases; CINAHL, Medline, PsycINFO and Sociological abstracts, were used for the literature search. In total 734 papers were screened, and 27 papers met the final inclusion criteria after assessment. Results: The synthesis reveals a need to create a space for childbirth underpinned by four aspects; a homely space, a spiritual space, a safe space, and a territorial space. Conclusion: Findings from this review will provide a basis for useful dialogue in midwifery education and in clinical settings.

Women's experiences of fear of childbirth: a metasynthesis of qualitative studies

Purpose: Women’s experiences of pregnancy, labour and birth are for some pregnant women negative and they develop a fear of childbirth, which can have consequences for their wellbeing and health. The aim was to synthesize qualitative literature to deepen the understanding of women’s experiences of fear of childbirth.

Methods: A systematic literature search and a meta-synthesis that included 14 qualitative papers.

Results: The main results demonstrate a deepened understanding of women’s experiences of fear of childbirth interpreted through the metaphor “being at a point of no return”. Being at this point meant that the women thought there was no turning back from their situation, further described in the three themes: To suffer consequences from traumatic births, To lack warranty and understanding, and To face the fear.

Conclusions: Women with fear of childbirth are need of support that can meet their existential issues about being at this point of no return, allowing them to express and integrate their feelings, experiences and expectations during pregnancy, childbirth and after birth.

Women with fear after birth, i.e., after an earlier negative birth experience, need support that enables them to regain trust in maternity care professionals and their willingness to provide them with good care that offers the support that individual women require. Women pregnant for the first time require similar support to reassure them that other’s experiences will not happen to them.

Women's Views of and Responses to Maternity Services Rendered during Labor and Childbirth in Maternity Units in a Semi-Rural District in South Africa

Facility-based delivery is an important strategy to prevent poor labor outcomes, and midwives are at the center of maternal care. However, disrespectful and abusive maternal care by midwives is prevalent and leads to poor antenatal care utilization and increased numbers of home deliveries. The objective of the study was to assess the views of women about the care they received during labor and childbirth and describe the interactions between the women and the midwives. This was a qualitative study using in-depth interviews with women who had delivered in midwife obstetric units at a district hospital in Tshwane District, South Africa. Twenty-six women aged 18-41 years, and had delivered within the previous six months were selected, using purposive sampling. A thematic content analysis approach and NVivo11 computer software were used to identify emergent themes. Most women had had negative experiences of the maternity services they had received during labor and childbirth. Shouting and rude remarks by midwives caused tension between the midwives and the women and had created a major barrier for communication. The abuse and disrespect that the women were subjected to had created a hostile and uncaring environment for them. They felt stressed, fearful, and anxious throughout labor and childbirth. In response to the hostile environment, they employed manipulative tactics such as pushing before time in the hope of getting attention. These acts resulted in punitive responses from the midwives who joined forces against them, reprimanded, or ignored them. Good interactions, described as being respectful, approachable, and polite, and the sharing of information yielded positive experiences of maternity care. The state of maternity services rendered during labor and childbirth is counterproductive to the existing plan of increasing early antenatal care bookings and presentation to the facilities for labor and childbirth. There is a need to retrain midwives in the respectful care of women during labor and childbirth to facilitate a change in their attitudes.

Effects of Birthing Room Design on Maternal and Neonate Outcomes: A Systematic Review

Aim:

To summarize, categorize, and describe published research on how birthing room design influences maternal and neonate physical and emotional outcomes.

Background:

The physical healthcare environment has significant effects on health and well-being. Research indicates that birthing environments can impact women during labor and birth. However, summaries of the effects of different environments around birth are scarce.

Methods:

We conducted a systematic review, searching 10 databases in 2016 and 2017 for published research from their inception dates, on how birthing room design influences maternal and neonate physical and emotional outcomes, using a protocol agreed a priori. The quality of selected studies was assessed, and data were extracted independently by pairs of authors and described in a narrative analysis.

Results:

In total, 3,373 records were identified and screened by title and abstract; 2,063 were excluded and the full text of 278 assessed for analysis. Another 241 were excluded, leaving 15 articles presenting qualitative and quantitative data from six different countries on four continents. The results of the analysis reveal four prominent physical themes in birthing rooms that positively influence on maternal and neonate physical and emotional outcomes: (1) means of distraction, comfort, and relaxation; (2) raising the birthing room temperature; (3) features of familiarity; and (4) diminishing a technocratic environment.

Conclusions:

The evidence on how birthing environments affect outcomes of labor and birth is incomplete. There is a crucial need for more research in this field.

Room4Birth - the effect of an adaptable birthing room on labour and birth outcomes for nulliparous women at term with spontaneous labour start: study protocol for a randomised controlled superiority trial in Sweden

Background

An important prerequisite for optimal healthcare is a secure, safe and comfortable environment. There is little research on how the physical design of birthing rooms affects labour, birth, childbirth experiences and birthing costs. This protocol outlines the design of a randomised controlled superiority trial (RCT) measuring and comparing effects and experiences of two types of birthing rooms, conducted in one labour ward in Sweden.

Methods/design

Following ethics approval, a study design was developed and tested for feasibility in a pilot study, which led to some important improvements for conducting the study. The main RCT started January 2019 and includes nulliparous women presenting to the labour ward in active, spontaneous labour and who understand either Swedish, Arabic, Somali or English. Those who consent are randomised on a 1:1 ratio to receive care either in a regular room (control group) or in a newly built birthing room designed with a person-centred approach and physical aspects (such as light, silencer, media installation offering programmed nature scenes with sound, bathtub, birth support tools) that are changeable according to a woman’s wishes (intervention group). The primary efficacy endpoint is a composite score of four outcomes: no use of oxytocin for augmentation of labour; spontaneous vaginal births (i.e. no vaginal instrumental birth or caesarean section); normal postpartum blood loss (i.e. bleeding < 1000 ml); and a positive overall childbirth experience (7–10 on a scale of 1–10). To detect a difference in the composite score of 8% between the groups we need 1274 study participants (power of 80% with significance level 0.05). Secondary outcomes include: the four variables in the primary outcome; other physical outcomes of labour and birth; women’s self-reported experiences (the birthing room, childbirth, fear of childbirth, health-related quality of life); and measurement of costs in relation to the hospital stay for mother and neonate. Additionally, an ethnographic study with participant observations will be conducted in both types of birthing rooms.

Discussion

The findings aim to guide the design of birthing rooms that contribute to optimal quality of hospital-based maternity care.

Trial registration

ClinicalTrials.gov NCT03948815. Registered 13 May 2019—retrospectively registered.

Midwives' care on a labour ward prior to the introduction of a midwifery model of care: a field of tension

Purpose: There is a need to deepen knowledge about midwives’ care in obstetric-led labour wards in which midwives are responsible for normal births. This ethnographic study explores the content and meaning of midwives’ care of women in a hospital-based labour ward in Sweden prior to the introduction of a theoretical midwifery model of care. Methods: Data were gathered through participant observation, analysed through interpretation grounded in reflexivity discussions and are presented in the form of ethnographic descriptions. Results: The midwives’ care was provided in a field of tension in which they had to balance contrasting models of care, described in the themes: The birthing rooms and the office—Different rooms of care, Women giving birth or being delivered—Midwives’ expectations and relationships with women, Old and new caring roles of the midwife—Women giving birth in a “new age”, Being and doing—Different approaches to caring, and Holistic and reductionist care—Guided by contrasting models and guidelines. The midwives’ freedom to act as autonomous professionals was hindered by medical and institutional models of care and this led to uncertainty regarding their roles as midwives. Conclusions: Midwives having to balance their activities in a field of tension require midwifery models that can guide their practice.

Women's labour experiences and quality of care in relation to a prolonged latent phase of labour

AIM

To describe primiparous and multiparous women's labour experiences and their perception of quality of intrapartum care, in relation to background characteristics and length of latent phase of labour prior to admittance to labour ward.

DESIGN

A cross-sectional study.

SETTING

A middle-sized hospital in a rural county in western part of Sweden.

PARTICIPANTS

Primiparous and multiparous women, both low-risk and risk, with a spontaneous onset of labour after gestational week 37+0 were included. In total, n = 1193 women were invited, and n = 757 responded the questionnaire, n = 342 primiparous and n = 415 multiparous women.

METHODS

The Intrapartal-specific Quality from Patient Perspective (QPP-I), with responses on perceived reality and subjective importance, was used for data collection. QPP-I covers ten factors of quality of care. Background characteristics, length of latent phase of labour, global items about labour experience and items regarding feelings during labour and birth were included. Data were analysed with descriptive and analytic statistics.

FINDINGS

All factors in QPP-I were rated higher for subjective importance than perceived reality, except for information about selfcare, for both primi- and multiparous women. Labour experience, perceived reality of quality of care, and feelings were related to length of the latent phase of labour. Primiparous women with a prolonged latent phase (>18 h) had significantly lower scores regarding six out of ten QPP-I factors (PR); Information procedures, Information self-care, Commitment (midwives), Commitment (enrolled nurses), Midwives present, and Partner/ significant others. They scored lower on Experience birth as normal and Safe during labour and birth. The felt less proud and felt more ignored by professionals. Multiparous women with a prolonged latent phase of labour scored significantly lower on one QPP-I factor, Commitment (midwives). They also scored lower on Control over the situation and felt less safe during labour and birth.

KEY CONCLUSION

Women's perception of quality of intrapartum care, the birth experience and feelings are related to length of the latent phase of labour. Women perceive quality of intrapartum care as being lower than its subjective importance.

IMPLICATIONS FOR PRACTICE

A prolonged latent phase of labour can be regarded as a risk factor for a more negative birthing experience.

Nontechnical skills and decision making in operative vaginal delivery

Nontechnical skills are defined as social, cognitive and personal resource skills that are necessary to conduct any technical skill safely. Whilst the skills are categorised into three domains: social, cognitive and personal resources, these are dependent on each other and the development and effectiveness of one relies on the other two. Effective nontechnical skills are essential in the safe care of patients in any setting, and their importance can be clearly demonstrated in the safe development of skills in many areas of medicine and surgery. Increasingly the importance of these skills is being recognised in outcomes for patients and staff, and training courses and assessment tools are being developed and used in obstetrics. Understanding of the role of nontechnical skills in labour and especially in operative vaginal births should be embedded across the specialty. Further research is needed in validation of assessment tools for these skills when used in obstetrics.

Links between patient safety and fear of childbirth-A meta-study of qualitative research

AIM

To conduct a meta-study of qualitative empirical research to explore the links between patient safety and fear of childbirth in the maternity care context. The review questions were: How are patient safety and fear of childbirth described? and What are the links between patient safety and fear of childbirth in the maternity care context?

DESIGN

Meta-study.

DATA SOURCES

The CINAHL, Cochrane, PubMed, Webb of Science, Proquest and Medline (Ovid) electronic databases were searched for articles published between June 2000-June 2016.

REVIEW METHODS

A meta-study of qualitative research with a thematic analysis followed by a synthesis.

RESULTS

Four descriptive themes emerged: "Physical risks associated with giving birth vaginally"; "Control and safety issues"; "Preventing psychological maternal trauma and optimizing foetal well-being"; and "Fear of the transition to motherhood due to lack of confidence". The two overarching analytical themes: "Opting for safety" and "An insecure environment breeds fear of childbirth", represent a deeper understanding and constitute the synthesis of the links between patient safety and fear of childbirth. This meta-study indicates the need for increased commitment to safe care and professional support to reduce risks and prevent unnecessary harm in maternity care.

Effects of the birthing room environment on vaginal births and client-centred outcomes for women at term planning a vaginal birth: BE-UP, a multicentre randomised controlled trial

Background

Caesarean sections (CSs) are associated with increased risk for maternal morbidity and mortality. The recommendations of the recently published German national health goal ‘Health in Childbirth’ (Gesundheit rund um die Geburt) promote vaginal births (VBs).

This randomised controlled trial (RCT) evaluates the effects of a complex intervention pertaining to the birth environment, based on the sociology of technical artefacts and symbolic interactionism. The intervention is intended to foster an upright position and mobility during labour, which lead to a higher probability of VB.

Methods/design

This study is an active controlled superiority trial with a two-arm parallel design. The complex intervention involves making changes to the birthing room to encourage an upright position and mobility of women in labour and to relax them, which may help them to cope with labour and may increase self-determination. This may result in more VBs. Included in the study are primiparae and multiparae with a singleton foetus in cephalic presentation at term planning a VB. According to the sample size calculation, 3800 women in 12 obstetrical units are to be included. Randomisation will be performed centrally and controlled by an independent coordination centre. Blinding of participants and staff is not possible. Key outcomes are VB, episiotomy, perineal tears, epidural analgesia, critical outcome of newborn at term and maternal self-determination during birth. Additionally, a health economic evaluation will be performed.

Discussion

This is the first adequately powered multicentre RCT examining the effect of a redesigned birthing room on the probability of a VB and patient-centred physical and emotional outcomes. An increase in the number of VBs by 5% from a baseline of 74% to 79% would result in 21,000 women per year experiencing a VB rather than a CS in Germany. Expected benefits are greater self-determination during labour, improved physical and emotional client-centred outcomes, fewer medical interventions and a reduction in health-care costs.

Trial registration

German Clinical Trials Register (Deutsches Register Klinischer Studien), DRKS00012854. Registered on 7 March 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2979-7) contains supplementary material, which is available to authorized users.

Childbirth experiences and their derived meaning: a qualitative study among postnatal mothers in Mbale regional referral hospital, Uganda

BACKGROUND

Evidence shows that negative childbirth experiences may lead to undesirable effects including failure to breastfeed, reduced love for the baby, emotional upsets, post-traumatic disorders and depression among mothers. Understanding childbirth experiences and their meaning could be important in planning individualized care for mothers. The purpose of this study was to explore childbirth experiences and their meaning among postnatal mothers.

METHODS

A phenomenological qualitative study was conducted at Mbale Regional Referral Hospital among 25 postnatal mothers within two months after birth using semi-structured interviews and focus group discussions and data was thematically analyzed.

RESULTS

The severity, duration and patterns of labour pains were a major concern by almost all women. Women had divergent feelings of yes and no need of biomedical pain relief administration during childbirth. Mothers were socially orientated to regard labour pains as a normal phenomenon regardless of their nature. The health providers' attitudes, care and support gave positive and negative birth experiences. The Physical and psychosocial support provided comfort, consolation and encouragement to the mothers while inappropriate care, poor communication and compromised privacy contributed to the mothers' negative childbirth experiences. The type of birth affected the interpretations of the birth experiences. Women who gave birth vaginally, thought they were strong and brave, determined and self-confident; and were respected by members of their communities. On the contrary, the women who gave birth by operation were culturally considered bewitched, weak and failures.

CONCLUSION

Childbirth experiences were unique; elicited unique feelings, responses and challenges to individual mothers. The findings may be useful in designing interventions that focus on individualized care to meet individual needs and expectations of mothers during childbirth.

Cesarean Section in the Delivery Room: An Exploration of the Viewpoint of Midwives, Anaesthesiologists, and Obstetricians

Aim

To explore the attitude and vision of midwives, anaesthesiologists, and obstetricians concerning a dedicated operating room for cesarean sections within the delivery ward versus cesarean sections within the general operating room.

Method

A descriptive qualitative study using a constructive paradigm. Face-to-face semistructured interviews were performed in 3 different hospitals, one without operating theatre within the delivery ward, one with a recently built cesarean section room within the delivery ward, and one with a long time tradition of cesarean section in the delivery room. Interviews have been analysed thematically.

Results

Three themes have been identified: organization, role of the midwife, and safety. Although identical protocols for the degree of emergency of a cesarean section are used, infrastructure and daily practice differ between hospitals. Logistic support, medical and midwife staffing, and hospital infrastructure are systematically mentioned as needing improvement. Realizing cesarean section within the delivery ward was considered as an improvement for the patient's experience. Midwives need a clear and new job description and delineation and mention a lack of formal education to assist surgical procedures. To increase patient safety continuous education and communication are considered necessary.

Conclusion

A detailed job description and education of all those involved in cesarean section at the delivery ward are necessary to improve patient safety. Patient experience is improved, but our knowledge on this is hampered by lack of studies.

A cross-country survey of attitudes toward childbirth technologies and interventions among university students

PROBLEM & AIM

Cultural beliefs that equate birth technology with progress, safety and convenience contribute to widespread acceptance of childbirth technology and interventions. Little is known about attitudes towards childbirth technology and interventions among the next generation of maternity care users and whether attitudes vary by country, age, gender, childbirth fear, and other factors.

METHODS

Data were collected via online survey in eight countries. Students who had never had children, and who planned to have at least one child were eligible to participate.

FINDINGS

The majority of participants (n=4569) were women (79.3%), and the median age was 22 years. More than half of students agreed that birth technology makes birth easier (55.8%), protects babies from harm (49.1%) and that women have a right to choose a medically non-indicated cesarean (50.8%). Respondents who had greater acceptance of childbirth technology and interventions were from countries with higher national caesarean birth rates, reported higher levels of childbirth fear, and were more likely to report that visual media or school-based education shaped their attitudes toward birth. Positive attitudes toward childbirth technology and interventions were also associated with less confidence in knowledge of birth, and more common among younger and male respondents.

DISCUSSION/CONCLUSION

Educational strategies to teach university students about pregnancy and birth in ways that does not frighten them and promotes critical reflection about childbirth technology are needed. This is especially true in countries with high rates of interventions that reciprocally shape culture norms, attitudes, and expectations.

A qualitative exploration of techniques used by expert midwives to preserve the perineum intact

BACKGROUND

The perineum stretches during birth to allow passage of the baby, but 85% of women sustain some degree of perineal trauma during childbirth, which is painful post-partum. Episiotomy rates vary significantly, with some countries having rates of >60%. Recent Irish and New Zealand studies showed lower severe perineal trauma and episiotomy rates than other countries.

AIM

To explore expert Irish and New Zealand midwives' views of the skills that they employ in preserving the perineum intact during spontaneous vaginal birth.

METHODS

Following ethical approval a qualitative, descriptive study was undertaken. Semi-structured, recorded, interviews were transcribed and analysed using the constant comparative method. Expert midwives employed in New Zealand and one setting in Ireland, were invited to join the study. "Expert" was defined as achieving, in the preceding 3.5 years, an episiotomy rate for nulliparous women of <11.8%, a 'no suture' rate of 40% or greater, and a severe perineal tear rate of <3.2%. Twenty-one midwives consented to join the study.

RESULTS

Four core themes emerged: 'Calm, controlled birth', 'Position and techniques in early second stage', 'Hands on or off?' and 'Slow, blow and breathe the baby out.' Using the techniques described enabled these midwives to achieve rates, in nulliparous women, of 3.91% for episiotomy, 59.24% for 'no sutures', and 1.08% for serious lacerations.

CONCLUSIONS

This study provides further understanding of the techniques used by expert midwives at birth. These findings, combined with existing quantitative research, increases the evidence on how to preserve the perineum intact during spontaneous birth.

Thematic Analysis of Women's Perspectives on the Meaning of Safety During Hospital-Based Birth

OBJECTIVE

To explore women's birth experiences to develop an understanding of their perspectives on patient safety during hospital-based birth.

DESIGN

Qualitative description using thematic analysis of interview data.

PARTICIPANTS

Seventeen women ages 29 to 47 years.

METHODS

Women participated in individual or small group interviews about their birth experiences, the physical environment, interactions with clinicians, and what safety meant to them in the context of birth. An interdisciplinary group of five investigators from nursing, medicine, product design, and journalism analyzed transcripts thematically to examine how women experienced feeling safe or unsafe and identify opportunities for improvements in care.

RESULTS

Participants experienced feelings of safety on a continuum. These feelings were affected by confidence in providers, the environment and organizational factors, interpersonal interactions, and actions people took during risk moments of rapid or confusing change. Well-organized teams and sensitive interpersonal interactions that demonstrated human connection supported feelings of safety, whereas some routine aspects of care threatened feelings of safety.

CONCLUSION

Physical and emotional safety are inextricably embedded in the patient experience, yet this connection may be overlooked in some inpatient birth settings. Clinicians should be mindful of how the birth environment and their behaviors in it can affect a woman's feelings of safety during birth. Human connection is especially important during risk moments, which represent a liminal space at the intersection of physical and emotional safety. At least one team member should focus on the provision of emotional support during rapidly changing situations to mitigate the potential for negative experiences that can result in emotional harm.

Being in a bubble - Childbirth as a potential path towards becoming in health - Lived experiences of mothers during childbirth

BACKGROUND

Childbirth is often seen as an existentially important life event. However, few studies focus on the experience from the woman's perspective.

THE AIM AND RESEARCH QUESTIONS

The aim of this study was to explore women's experiences of strength and health during childbirth through an ontological understanding. What enables women to experience strength and health during childbirth?

RESEARCH DESIGN, PARTICIPANTS AND RESEARCH CONTEXT

A hermeneutical approach was used. The material consists of texts from interviews with eight women who have recently (a few days to some weeks) given birth. The texts were interpreted through latent content analysis.

ETHICAL CONSIDERATIONS

Informed consent was sought from the participants regarding participation in the study and the storage and handling of data for research purposes.

FINDINGS

The overall theme was 'Childbirth as a movement towards becoming in health'. The three main themes were as follows: 'The self as a source of strength', 'The other as a source of strength in communion' and 'Alleviation of suffering as a source of strength'. Seven subthemes were also described.

CONCLUSION

Childbirth may be seen as a potential path towards becoming in health. The midwife has a central position in supporting women's experiences of health. Family-centred care may enhance women's experiences of becoming in health during childbirth. Further research in this field should focus on revealing midwives' perspectives on what gives women health in connection with childbirth.

Exploring the strategies that midwives in British Columbia use to promote normal birth

BACKGROUND

Rates of normal birth have been declining steadily over the past 20 years, despite the evidence of the benefits to mother and baby. This is most obvious in steadily increasing caesarean section rates across countries and studies of the factors involved suggest it may be more to do with the organization of maternity care and the preferences of healthcare providers than changes in maternal or demographic conditions. The proportion of women in British Columbia (BC) receiving care from a midwife continues to grow and there is a particular focus on promoting and supporting normal pregnancy and birth in the midwifery philosophy of care. In BC, women receiving care from a midwife are less likely to have a caesarean section and other birth interventions.

METHODS

An interpretive approach, based on interpretive phenomenology was used to explore the experiences of midwives in BC of normal birth and the strategies that they use to keep birth normal. Fourteen experienced midwives were purposively selected from across the range of practice, geographical, and rural/urban contexts to participate in depth interviews. Data were analyzed using Thematic Network Analysis.

RESULTS

Seven key themes were identified in the data: working with women from the early pregnancy, informing choice, the birth environment, careful watching and waiting, managing early labour, helping the woman to cope with labour, and tools in the tool kit.

CONCLUSIONS

Midwives in BC work closely with women from early pregnancy to prepare them for a normal birth, and as "instruments of care" they adopt a range of approaches to support women to achieve this. The emphasis on continuity of care in the BC model of midwifery care plays a vital role in this.

Clinicians' views of factors of importance for improving the rate of VBAC (vaginal birth after caesarean section): a study from countries with low VBAC rates

BACKGROUND

Caesarean section (CS) rates are increasing worldwide and the most common reason is repeat CS following previous CS. For most women a vaginal birth after a previous CS (VBAC) is a safe option. However, the rate of VBAC differs in an international perspective. Obtaining deeper knowledge of clinicians' views on VBAC can help in understanding the factors of importance for increasing VBAC rates. Focus group interviews with clinicians and women in three countries with high VBAC rates (Finland, Sweden and the Netherlands) and three countries with low VBAC rates (Ireland, Italy and Germany) are part of "OptiBIRTH", an ongoing research project. The study reported here aims to explore the views of clinicians from countries with low VBAC rates on factors of importance for improving VBAC rates.

METHODS

Focus group interviews were held in Ireland, Italy and Germany. In total 71 clinicians participated in nine focus group interviews. Five central questions about VBAC were used and interviews were analysed using content analysis. The analysis was performed in each country in the native language and then translated into English. All data were then analysed together and final categories were validated in each country.

RESULTS

The findings are presented in four main categories with several sub-categories: 1) "prameters for VBAC", including the importance of the obstetric history, present obstetric factors, a positive attitude among those who are centrally involved, early follow-up after CS and antenatal classes; 2) "organisational support and resources for women undergoing a VBAC", meaning a successful VBAC requires clinical expertise and resources during labour; 3) "fear as a key inhibitor of successful VBAC", including understanding women's fear of childbirth, clinicians' fear of VBAC and the ways that clinicians' fear can be transferred to women; and 4) "shared decision making - rapport, knowledge and confidence", meaning ensuring consistent, realistic and unbiased information and developing trust within the clinician-woman relationship.

CONCLUSIONS

The findings indicate that increasing the VBAC rate depends on organisational factors, the care offered during pregnancy and childbirth, the decision-making process and the strategies employed to reduce fear in all involved.

Birth Environments: A Woman's Choice in the 21st Century

A woman has many important decisions to make once discovering a pregnancy. One of those decisions with significant implications is where the birth will take place. The primary consideration for the majority of pregnant women when making a decision about birth environment is safety. However, other factors such as attitudes of family and friends, religious reasons, and confidence in the body's ability to give birth play a factor in the choice of birth environment. It is recommended that birth attendants use the process of shared decision making to assist pregnant women in making choices related to the birth environment. This process empowers the pregnant woman and provides a woman-centered and evidence-based approach to choices related to obstetrical care.

Women's experience of intrapartum transfer from a Western Australian birth centre co-located to a tertiary maternity hospital

BACKGROUND

The aim of this Western Australian study was to describe the overall labour and birth experience of women who were transferred during the first and second stages of labour from a low risk woman-centred, midwifery-led birth centre to a co-located tertiary maternity referral hospital.

METHODS

Using a descriptive phenomenological design, fifteen women were interviewed up to 8 weeks post birth (July to October, 2013) to explore their experience of the intrapartum transfer. Giorgi's method of analysis was used.

RESULTS

The following themes and subthemes emerged: 1) The midwife's voice with subthemes, a) The calming effect and b) Speaking up on my behalf; 2) In the zone with subthemes, a) Hanging in there and b) Post birth rationalizing; 3) Best of both worlds with subthemes a) The feeling of relief on transfer to tertiary birth suite and b) Returning back to the comfort and familiarity of the birth centre; 4) Lost sense of self; and 5) Lost birth dream with subthemes a) Narrowing of options and b) Feeling of panic. Women found the midwife's voice guided them through the transfer experience and were appreciative of continuity of care. There was a sense of disruption to expectations and disappointment in not achieving the labour and birth they had anticipated. There was however appreciation that the referral facility was nearby and experts were close at hand. The focus of care altered from woman to fetus, making women feel diminished. Women were glad to return to the familiar birth centre after the birth with the opportunity to talk through and fully understand their labour journey which helped them contextualise the transfer as one part of the whole experience.

CONCLUSIONS

Findings can inform midwives of the value of a continuity of care model within a birth centre, allowing women both familiarity and peace of mind. Maternity care providers should ensure that the woman remains the focus of care after transfer and understand the significance of effective communication to ensure women are included in all care discussions.