A metaethnography of traumatic childbirth and its aftermath: amplifying causal looping

Sacred space: a qualitative interpretive meta-synthesis of women's experiences of supportive birthing environments

BACKGROUND

In the United States there are roughly three million births a year, ranging from cesarean to natural births. A major aspect of the birthing process is related to the healing environment, and how that helps or harms healing for the mother and child. Using the theoretical framework, Theory of Supportive Care Settings (TSCS), this study aimed to explore what is necessary to have a safe and sacred healing environment for mothers.

METHOD

This study utilized an updated Qualitative Interpretive Meta-synthesis (QIMS) design called QIMS-DTT [deductive theory testing] to answer the research question, What are mother's experiences of environmental factors contributing to a supportive birthing environment within healthcare settings?

RESULTS

Key terms were run through multiple databases, which resulted in 5,688 articles. After title and abstract screening, 43 were left for full-text, 12 were excluded, leaving 31 to be included in the final QIMS. Five main themes emerged from analysis: 1) Service in the environment, 2) Recognizing oneself within the birthing space, 3) Creating connections with support systems, 4) Being welcomed into the birthing space, and 5) Feeling safe within the birthing environment.

CONCLUSIONS

Providing a warm and welcoming birth space is crucial for people who give birth to have positive experiences. Providing spaces where the person can feel safe and supported allows them to find empowerment in the situation where they have limited control.

Effect of psychological interventions on mental health, personal relationships and quality of life of women who have subjectively experienced traumatic childbirth

BACKGROUND

No targeted review has assessed the effect of psychological interventions on the mental health, personal relationships, and the quality of life of women who have subjectively experienced traumatic childbirth.

METHODS

Eight databases were searched from inception to January 2023. Study selection, data extraction, quality appraisal, and data analysis were conducted by two researchers independently.

RESULTS

In total, eight studies were included. The results indicated that psychological interventions could effectively alleviate post-traumatic stress disorder (PTSD) symptoms, depression, and anxiety in women who have subjectively experienced traumatic childbirth. The interventions were more effective in alleviating PTSD symptoms than depression or anxiety. The subgroup analysis results showed that the effect of multiple sessions might be better than that of a single session. There was insufficient evidence supporting the effect of psychological interventions to improve personal relationships and the quality of life.

LIMITATIONS

Study limitations included the small number of studies included for meta-analysis, substantial heterogeneity, and the retrieval of only studies written in English or Chinese.

CONCLUSIONS

Psychological intervention is a promising method for the mental health of women who have subjectively experienced traumatic childbirth, but more studies are needed to confirm the effects. More studies are also required to explore the impact of psychological interventions on personal relationships and the quality of life. Future studies should focus on comparing which specific type of psychological intervention is most effective. Additional investigations should include the potential adverse effects and long-term effects of psychological interventions and details, such as content, process, and timing.

The impact of birth trauma on the couple relationship and related support requirements; a framework analysis of parents' perspectives

BACKGROUND

Ongoing distress following a traumatic birth experience, commonly known as birth trauma, can lead to post-traumatic stress symptoms. Experiencing birth trauma can affect personal well-being and impact the couple relationship.

OBJECTIVE

The present study aimed to explore the lived experience of the impact of birth trauma on the couple relationship and related support requirements.

METHODS

A purposive sample of men and women in the UK who had experienced birth as traumatic were recruited and interviewed remotely in 2021. Data were analysed using framework analysis in NVivo 12.

RESULTS

The sample (N=18) contained 9 women who were first time parents and 9 men; 5 of which were first time parents and 4 who had two children. Twelve themes are reported related to the impact of birth trauma on the couple relationship. Findings suggest the impact of birth trauma on the couple relationship can be negative and distressing, or for some lead to a strengthened relationship. Fourteen themes are reported related to associated birth trauma support. Negative aspects of support were reported in themes: unavailability of help from friends and family; unhelpful birth debriefing services; no personal awareness of birth trauma; absence of trauma validation from health care professionals; lack of awareness of the emotional needs of men; and barriers to accessing psychological services. Potential improvements to support included: supporting parents to understand the traumatic events; birth trauma informed antenatal preparation; improving access to specialist psychological services; and compassionate parent centred maternity services.

CONCLUSIONS

The impact of birth trauma on the couple relationship appears complex with both positive and negative affects reported. Current support for the impact of birth trauma on the couple relationship has perceived inadequacies for which improvements are proposed.

Navigating intensive altered states of consciousness: How can the set and setting key parameters promote the science of human birth?

The subjective childbirth experience is crucial from a public health standpoint. There is a correlation between a negative childbirth experience and a poor mental state after birth, with effects that go far beyond the postpartum (PP) period. This paper offers a new approach as to how birthing experiences, and birth in general, can be navigated. The theory of set and setting proves that psychedelic experiences are shaped, first and foremost, by the mindset of an individual entering a psychedelic experience (set) and by the surroundings in which the experience happens (setting). In research on altered states of consciousness during psychedelic experiences, this theory explains how the same substance can lead to a positive and life-changing experience or to a traumatic and frightening experience. Because recent studies suggest that birthing women enter an altered state of consciousness during physiological birth ("birthing consciousness"), I suggest analyzing the typical modern birthing experience in terms of set and setting theory. I argue that the set and setting key parameters can help design, navigate, and explain many psychological and physiological elements of the human birth process. Thus, an operative conclusion that emerges from the theoretical analysis presented in this paper is that framing and characterizing the birth environment and birth preparations in terms of set and setting is a central tool that could be used to promote physiological births as well as subjective positive birthing experiences, which is currently a primary, yet unreached goal, in modern obstetrics and public health.

Psychological birth trauma: A concept analysis

Aim

To define and analyze the concept of psychological birth trauma.

Design

The concept analysis method of Walker and Avant was used.

Method

Eight databases (PubMed, CINAHL Complete, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang, VIP Information Chinese Journal Service Platform, and Chinese BioMedicine Literature Database) were searched from inception to July 2022 for studies focused on psychological birth trauma.

Results

Of the 5,372 studies identified, 44 ultimately met the inclusion criteria. The attributes identified were (1) women's subjective feelings, (2) intertwined painful emotional experiences, (3) originating in the birth process, and (4) lasting until postpartum. Antecedents were divided into two groups: pre-existing antecedents and birth-related antecedents. Consequences were identified as negative and positive.

Conclusion

Psychological birth trauma is a more complex and comprehensive concept than previously thought, and should be regarded as a separate postpartum mental health problem. This study deepens the understanding of psychological birth trauma through a comprehensive concept analysis and also puts forward some suggestions for the prevention, identification, and intervention of psychological birth trauma, which provides a basis for assisting in the identification of psychological birth trauma and provides a reference for the development of rigorous assessment tools and the design of appropriate interventions in the future. Further research is needed to update and refine this concept.

Black, Asian and minority ethnic women's experiences of maternity services in the UK: A qualitative evidence synthesis

AIMS

Black, Asian and minority ethnic women are at higher risk of dying during pregnancy, childbirth and postnatally and of experiencing premature birth, stillbirth or neonatal death compared with their White counterparts. Discrimination against women from ethnic minorities is known to negatively impact women's ability to speak up, be heard and their experiences of care. This evidence synthesis analysed Black, Asian and minority ethnic women's experiences of UK maternity services in light of these outcomes.

DESIGN

We conducted a systematic review and qualitative evidence synthesis using the method of Thomas and Harden.

DATA SOURCES

A comprehensive search in AMED, Cinahl, Embase, Medline, PubMed and PsycINFO, alongside research reports from UK maternity charities, was undertaken from 2000 until May 2021. Eligible studies included qualitative research about antenatal, intrapartum and postnatal care, with ethnic minority women in maternity settings of the UK NHS.

REVIEW METHODS

Study quality was graded using the Critical Appraisal Skills Programme tool.

RESULTS

Twenty-four studies met the inclusion criteria. Our synthesis highlights how discriminatory practices and communication failures in UK NHS maternity services are failing ethnic minority women.

CONCLUSION

This synthesis finds evidence of mistreatment and poor care for ethnic minority women in the UK maternity system that may contribute to the poor outcomes reported by MBRRACE. Woman-centred midwifery care is reported as positive for all women but is often experienced as an exception by ethnic minority women in the technocratic birthing system.

IMPACT

Ethnic minority women report positive experiences when in receipt of woman-centred midwifery care. Woman-centred midwifery care is often the exception in the overstretched technocratic UK birthing system. Mistreatment and poor care reported by many ethnic minority women in the UK could inform the inequalities of outcomes identified in the MBRRACE report.

Women's experiences and perceptions of women-centered care and respectful care during facility-based childbirth: A meta-synthesis

AIM

The World Health Organization has recommended intrapartum care for a positive childbirth experience through respectful care based on women-centered care. This study aimed to explore women's experiences of facility-based childbirth to gain insights into their perceptions of women-centered care, including humanized childbirth and respectful maternity care during intrapartum care.

METHODS

Used the Joanna Briggs Institute method as the framework for this meta-synthesis, we searched the PubMed, EMBASE, CINAHL, PsycINFO, and LILCAS databases, and included qualitative studies and interviews of women's experiences and perceptions of women-centered care during facility-based childbirth published from 1990 to 2020 in English. Study quality was assessed using the Critical Appraisal Skills Programme checklist. NVivo software was used for data extraction and synthesis.

RESULTS

There were 22 studies from 19 countries that met the established inclusion criteria. Five categories of experiences of facility-based childbirth and perceptions of women-centered care from the synthesized voices of women were generated: (i) value of women through childbirth; (ii) overwhelmed by unpleasant childbearing experiences; (iii) a sense of being respected and valued; (iv) a sense of being disrespected and abused; and (v) inadequate systems and resources. Our meta-synthesis indicated that respectful and helpful interaction between women and healthcare providers produced positive perceptions among women.

CONCLUSIONS

This study emphasizes the importance of respectful interactions and intrapersonal experiences. Strong systems and positive environments lead to positive interactions between women and healthcare providers. Future studies need to consider cultural and economic differences in women-centered care and respectful care for childbirth in different contexts.

Women's experiences of VBAC in Cyprus: a qualitative study

BACKGROUND AND AIM

In 21st century, there has been an increasing interest in vaginal birth after previous caesarean section (VBAC) in Cyprus, a country with a very high operative birth rate. Research-based evidence of women's VBAC experiences in Cyprus is non-existent, despite its significance for the well-being of mothers and families. The aim of this study is to gain insight into the women's lived experience of VBAC in Cyprus. In this study women's experiences of VBAC are explored for the first time in Cyprus.

METHOD

The study is qualitative and exploratory in nature. Data were collected through semi-structured interviews with 10 women, who experienced vaginal birth after a previous caesarean section (VBAC) in Cyprus. A descriptive phenomenological approach was employed for the analysis of data.

RESULTS

Analysis of data yielded four major themes: (a) medicalization of childbirth, (b) preparing for a VBAC, (c) birth environment, and (d) healing through VBAC. On the whole, the women interviewed described their previous experience of CS as traumatic, in contrast to vaginal childbirth. VBAC was considered an utterly positive experience that made the women feel empowered and proud of themselves.

CONCLUSION

This study offers valuable insight into a newly researched subject in Cyprus, which is necessary for advancing perinatal care in Cyprus. The findings indicate that women need evidence-based information, guidelines on birthing options, good preparation with tailored information and personalized care for a successful vaginal birth after a previous caesarean section. Proper, non-biased, consultations are a main factor that affects women's choice of mode of birth. The introduction of new, women-friendly perinatal strategies that respect and promote childbirth rights is imperative in the case of Cyprus. All women have the right to exercise informed choice and the choice to alternative birthing options.

Feelings, Thoughts, and Behaviors During Disaster

Thoughts, feelings, and behaviors during traumatic events, that is, peritraumatic reactions, are key to post-trauma psychopathology development. Qualitative research is required to investigate whether existing quantitative methods capture the range and complexity of peritraumatic reactions as described by survivors. Semi-structured interviews were conducted with 104 earthquake survivors. Participants reported experiencing various peritraumatic reactions (M = 21, range = 6-43). The survivors' accounts confirmed presence and overall phenomenological characteristics of commonly studied peritraumatic reactions such as dissociation, distress, mental defeat, and immobility. In addition, novel and understudied reactions were identified: cognitive overload, hyperfocus, and emotion regulation, as well as positive affect. Finally, a number of cross-cutting phenomena were identified such as the social nature of many reactions and survivors evaluating their reactions as difficult to put into words. These findings have implications for the conceptualization of peritraumatic reactions, for trauma-focused psychotherapeutic interventions, and for the wellbeing of disaster survivors.

National Partnership for Maternal Safety: Consensus Bundle on Support After a Severe Maternal Event

Supporting women, families, and clinicians with information, emotional support, and health care resources should be part of an institutional response after a severe maternal event. A multidisciplinary approach is needed for an effective response during and after the event. As a member of the maternity care team, the nurse's role includes coordination, documentation, and ensuring patient safety in emergency situations. The National Partnership for Maternal Safety, under the guidance of the Council on Patient Safety in Women's Health Care, has developed interprofessional work groups to develop safety bundles on diverse topics. This article provides the rationale and supporting evidence for the support after a severe maternal event bundle, which includes structure- and evidence-based resources for women, families, and maternity care providers. The bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning, and it may be adapted by nurses and multidisciplinary leaders in birthing facilities for implementation as a standardized approach to providing support for everyone involved in a severe maternal event.

Ferguson v. City of Charleston Redux: Motivated Reasoning and Coercive Interventions in Pregnancy

Criminalization of perinatal substance use disorder and other coercive interventions in pregnancy (such as forced cesarean delivery or involuntary hospitalization for bed rest) directly affect the well-being of children and their families and, potentially, of all women of reproductive capacity. Untenable legal and policy approaches that occasion such incursions not only persist but affect a growing number of women. They are antithetical to healthy pregnancies, healthy children, and healthy families; they have the potential to reduce prenatal care seeking, divert attention and resources away from critical mental health and maternal and child support services, and epigenetically affect maternal and infant bonding. Punitive and coercive interventions contravene long-established guidance by professional associations that advocate for public health approaches and ethical frameworks to guide practice. Harmful policies persist because of motivated reasoning by clinicians, members of the judiciary, and ill-informed legislators who rely on personal experience and anecdote rather than evidence to fashion policy. Compounding the problem are inadequate substance use treatment resources and professional associations that choose not to hold their members accountable for violating their ethical obligations to their patients. Pediatricians must advocate for the cessation of coercive interventions within their institutions and their larger communities. All health care professionals should collaborate at the local, state, and national level to provide policymakers and legislators with data emphasizing the negative effects of punitive and coercive policies aimed at pregnant women and their children.

Vulnerability in birth: A negative capability

AIM

This article explores the literature on women's expectations for birth, the sociocultural context from which these expectations originate and their impact on the interpretation of birth experience.

BACKGROUND

Childbirth is associated with specific expectations from women with the potential for dissatisfaction if these expectations are not met.

DESIGN

This paper presents a systematic analysis of the concept of vulnerability in childbirth.

FINDINGS

A framework was extracted from the literature that linked the themes of a discourse of control, construction of inadequacy and shame of exposure to explain the sociocultural origin of dominant childbirth expectations in the literature. The experience of vulnerability unique to the birthing event is suggested as exposing the woman to this underlying contextual framework and impacting the interpretation of her birth.

CONCLUSION

This synthesis has exposed the transient experience of vulnerability during birth as a significant contributor to the birthing woman's interpretation of the birth and her place within it.

RELEVANCE TO CLINICAL PRACTICE

An explanatory framework is offered to clinicians that could increase their awareness of sociocultural and historical factors impacting a woman's expectations for birth. Appreciation of the woman's vulnerability in birth, exposing her to the influence of this framework, can assist clinicians to facilitate a quality birth experience for women. Furthermore, supporting women and midwives to accept this experience of birth vulnerability as a "negative capability," can facilitate an empowering birth experience.

Childbirth Experience Associated With Maternal and Paternal Stress During the First Year, but Not Child Attachment

Women, as well as their partners, can experience childbirth in many different ways. A negative childbirth experience may have adverse effects on the entire family, resulting, for instance, in parental stress symptoms and a weakened parent-child relationship. Parental stress, without sufficient resources to compensate for it, may also in and of itself negatively influence the parent-child relationship. This study contributes to the current knowledge of the psychological effects of childbirth experience by using longitudinal data collected with both self-reports and observational measures, as well as multiple informants (i.e., mothers and partners). The aim of this study was to investigate whether 1) women's retrospective birth experiences were related to maternal and paternal parenting stress, 2) birth experience was indirectly associated with child attachment via maternal stress, and 3) birth experience was directly related to child attachment. Data were collected from a mixed sample of community and at-risk primipara women (N = 1,364), as well as from their partners and children. Retrospective childbirth experience was measured 3 months postpartum with a latent factor consisting of five items asking about the feelings that women have about their childbirth. Parental stress was measured at 3 months postpartum for partners and 3 and 12 months postpartum for mothers using the adult domain of the parental stress index (PSI). Finally, parent-child attachment is observed in a subsample of 223 women and children at 12 months postpartum with the Strange Situation Procedure (SSP). Results show that women's birth experience was significantly related to both mothers' and their partners' parenting stress. However, birth experience was not related to child attachment, neither directly nor indirectly via maternal stress. These findings emphasize the long-lasting impact that childbirth may have on both parents. Future research is still needed to further investigate which protective factors may weaken the association between birth experience and parental stress.

Women's decision-making processes and experiences of vaginal birth after caesarean birth: A phenomenological study

AIM

To discover, identify, and interpret the decision-making processes and experiences of women on vaginal birth after caesarean section.

METHODS

This Husserlian phenomenological qualitative study was conducted using semistructured individual interviews with 12 women who experienced vaginal birth after caesarean section between August and December 2017. Colaizzi's qualitative analysis method was used.

RESULTS

Four themes emerged: "finding a way to have vaginal birth after caesarean section," "healing by giving birth," "advantageous birth," and "being at the centre of the care," with 13 subthemes. Women defined vaginal birth after caesarean section as an important aspect of their femininity and a sense of motherhood. The women noted that traumatic experiences in caesarean section birth had been removed with vaginal birth and regarded this as an important spiritual experience and life event. The women reported that the important advantage of vaginal birth after caesarean section was not being in need of others in the post-partum period. However, women described negative experiences where health care professionals did not respect their birth preference or provide adequate information and support.

CONCLUSIONS

Continuing professional development training is recommended in order to improve health care professionals' caring consciousness about the importance of shared decision making for women's birth type.

The Blind Men and the Elephant: Meta-Ethnography 30 Years On

In the 30 years since its introduction, meta-ethnography has become a critical tool for synthesizing qualitative health research and providing a holistic understanding of complex health and social phenomena. Meta-ethnography has also been adapted to integrate a wider range of research methodologies, expanded to include a detailed taxonomy of research methods, and has led to the development of multiple other methods of synthesis. In this article, we describe the development of meta-ethnography, its unique research approaches, the innovations that have occurred since its inception, and potential future directions for the method. These include the need for consensus around the role of systematic database searches and critical appraisal, and a clearer path to action for clinicians interpreting qualitative research. Understanding and updating methods such as meta-ethnography will ensure that the exponentially developing field of qualitative research continues to have a meaningful and cumulative impact on complex issues of health and well-being.

A narrative analysis of women's experiences of planning a vaginal birth after caesarean (VBAC) in Australia using critical feminist theory

BACKGROUND

Most women who have a caesarean can safely have a vaginal birth after caesarean (VBAC) for their next birth, but more women have an elective repeat caesarean than a VBAC.

METHODS

The aim of this qualitative study was to explore the experiences of women planning a vaginal birth after caesarean (VBAC) in Australia, the interactions with their health care providers and their thoughts, feelings and experiences after an antenatal appointment and following the birth. The study explored the effect of different models of care on women's relationships with their health care provider using a feminist theoretical lens. Eleven women who had previously experienced a caesarean section and were planning a VBAC in their current pregnancy used the 'myVBACapp' to record their thoughts after their antenatal appointments and were followed up with in-depth interviews in the postnatal period.

RESULTS

Fifty-three antenatal logs and eleven postnatal interviews were obtained over a period of eight months in 2017. Women accessed a variety of models of care. The four contextual factors found to influence whether a woman felt resolved after having a VBAC or repeat caesarean were: 'having confidence in themselves and in their health care providers', 'having control', 'having a supportive relationship with a health care provider' and 'staying active in labour'.

CONCLUSIONS

The findings highlight that when women have high feelings of control and confidence; have a supportive continual relationship with a health care provider; and are able to have an active labour; it can result in feelings of resolution, regardless of mode of birth. Women's sense of control and confidence can be undermined through the impact of paternalistic and patriarchal maternity systems by maintaining women's subordination and lack of control within the system. Women planning a VBAC want confident, skilled, care providers who can support them to feel in control and confident throughout the birthing process. Continuity of care (CoC) provides a supportive relationship which some women in this study found beneficial when planning a VBAC.

Perspectives of older people about contingency planning for falls in the community: A qualitative meta-synthesis

Objective

Despite consistent evidence for the positive impact of contingency planning for falls in older people, implementation of plans often fail. This is likely due to lack of recognition and knowledge about perspectives of older people about contingency planning. The objective of this research was to explore the perspectives of older people living in the community about use of contingency planning for getting help quickly after a fall.

Method

A systematic literature search seeking qualitative research was conducted in April 2014, with no limit placed on date of publication. Medline, EMBASE, Ageline, CINAHL, HealthSource- Nursing/Academic Edition, AMED and Psych INFO databases were searched. Three main concepts were explored and linked using Boolean operators; older people, falls and contingency planning. The search was updated until February 2016 with no new articles found. After removal of duplicates, 562 articles were assessed against inclusion and exclusion criteria resulting in six studies for the meta-synthesis. These studies were critically appraised using the McMaster critical appraisal tool. Bespoke data extraction sheets were developed and a meta-synthesis approach was adopted to extract and synthesise findings.

Findings

Three themes of ‘a mix of attitudes’, ‘careful deliberations’ and ‘a source of anxiety’ were established. Perspectives of older people were on a continuum between regarding contingency plans as necessary and not necessary. Levels of engagement with the contingency planning process seemed associated with acceptance of their risk of falling and their familiarity with available contingency planning strategies.

Conclusion

Avoiding a long lie on the floor following a fall is imperative for older people in the community but there is a lack of knowledge about contingency planning for falls. This meta-synthesis provides new insights into this area of health service delivery and highlights that implementation of plans needs to be directed by the older people rather than the health professionals.

Women’s Experience of Birth: Childbirth as a Rite of Passage

BACKGROUND: Within midwifery, there is a move toward reclaiming and promoting physiological birth. Because midwifery is woman-centered in nature, it is essential that the experience of birth is understood from the woman’s perspective. To date, there has been little research focusing exclusively on women’s experience of physiological birth.

AIM: The aim of this study was to explore women’s experiences of physiological birth.

METHOD: A narrative approach was taken, and in-depth face-to-face interviews were used to gather birth stories. The participants were 10 women who had recently experienced a physiological birth. Data were analyzed to identify themes occurring across the narratives.

FINDINGS: The findings are presented within the explanatory framework of childbirth as a rite of passage composing of three phases: separation, liminal, and incorporation. During birth, women separated from the external world and sought to minimize external and internal distractions. In the liminal phase, they entered “their own world” and experienced an altered state of consciousness. After their baby was born, they reintegrated with the external world and incorporated their birth experience into their sense of self.

CONCLUSION: The findings of this study suggest that women’s experiences during physiological birth are multidimensional and not aligned with biomedical descriptions of physically defined stages of labor. Birth was an empowering and transformative experience for the women in the study. The rites of passage framework may assist with developing a discourse about birth that resonates with women’s experiences.

At pains to consent: A narrative inquiry into women's attempts of natural childbirth

BACKGROUND

With only 1.2% of all annual U.S. births registered as out-of-hospital births, national trends show an increase in medicalised hospital births. Caesarean sections have become the most common surgical procedure in the U.S.; Caesarean section rates have increased from 20.6% in 1997 to 31.5% in 2009. Furthermore, in 2009, 67% of hospital births utilised epidural analgesia and 26% used oxytocin augmentation. In response to the increased medicalisation of childbirth within the U.S., some women resist standardised medical procedures and instead choose to labour and birth without medical intervention.

AIM

The purpose of this study was to understand and contextualise the childbirth experiences of first-time mothers who planned to have a natural childbirth (without medical intervention) in the Midsouthern United States.

METHODS

Using narrative inquiry, we collected data from six participants through semi-structured life-story interviews.

FINDINGS

Utilising thematic analysis, four recurring themes emerged: (1) benefits and limitations of pre-labour self-education; (2) labouring women's experiences of relationality; (3) the importance of birth stories and expectations; and (4) the creation of false dilemmas and complexities of "informed choice."

DISCUSSION AND CONCLUSION

The women's stories suggest that U.S. medical establishments, the media, and society need to empower pregnant and birthing women by creating new narratives of labour and positive spaces of relationality. Furthermore, health care professionals need to critically examine their usage of the medical model of care while respecting women's choices and agency.

Women's reasons for, and experiences of, choosing a homebirth following a caesarean section

Background

Caesarean section is rising in the developed world and vaginal birth after caesarean (VBAC) is declining. There are increased reports of women seeking a homebirth following a caesarean section (HBAC) in Australia but little is known about the reasons for this study aimed to explore women's reasons for and experiences of choosing a HBAC.

Methods

Twelve women participated in a semi-structured one-to-one interview. The interviews were digitally recorded, then transcribed verbatim. These data were analysed using thematic analysis.

Results

The overarching theme that emerged was ‘It’s never happening again’. Women clearly articulated why it [caesarean section] was never happening again under the following sub themes: ‘treated like a piece of meat’, ‘I was traumatised by it for years’, ‘you can smell the fear in the room’, ‘re-traumatised by the system’. They also described how it [caesarean section] was never happening again under the sub themes: ‘getting informed and gaining confidence’, ‘avoiding judgment through selective telling’, ‘preparing for birth’, ‘gathering support’ and ‘all about safety but I came first’. The women then identified the impact of their HBAC under the subthemes ‘I felt like superwoman’ and ‘there is just no comparison’.

Conclusions

Birth intervention may cause physical and emotional trauma that can have a significant impact on some women. Inflexible hospital systems and inflexible attitudes around policy and care led some women to seek other options. Women report that achieving a HBAC has benefits for the relationship with their baby. VBAC policies and practices in hospitals need to be flexible to enable women to negotiate the care that they wish to have.

Middle Range Theory of Traumatic Childbirth: The Ever-Widening Ripple Effect

A middle range theory of traumatic childbirth was developed using Morse’s method of theoretical coalescence. The scope of this qualitative theory was increased by formalizing the connections between 14 individual studies all conducted by the same researcher on the same topic, with different groups, using different research designs and different types of analyses. Axioms were derived from this research program along with attributes of traumatic childbirth, posttraumatic stress, and secondary traumatic stress. This middle range theory addresses the long-term chronic consequences of a traumatic birth for mothers including its impact on breastfeeding, subsequent childbirth, and the anniversary of birth trauma. The impact on fathers and clinicians present at the traumatic birth is highlighted as secondary traumatic stress comes into play. Troubling glimpses of difficulties in mother–infant bonding are revealed.

Severe maternal morbidity and breastfeeding outcomes in the early post-natal period: a prospective cohort study from one English maternity unit

Previous research has identified potential issues of establishing and maintaining breastfeeding among women who experience severe maternal morbidity associated with pregnancy and birth, but evidence in the UK maternity population was scarce. We explored the association between severe maternal morbidity and breastfeeding outcomes (uptake and prevalence of partial and exclusive breastfeeding) at 6 to 8 weeks post-partum in a UK sample. Data on breastfeeding outcomes were obtained from a large cohort study of women who gave birth in one maternity unit in England to assess the impact of women's experiences of severe maternal morbidity (defined as major obstetric haemorrhage, severe hypertensive disorder or high dependency unit/intensive care unit admission) on their post-natal health and other important outcomes including infant feeding. Results indicated that among women who responded (n = 1824, response rate = 53%), there were no statistically significant differences in breastfeeding outcomes between women who did or did not experience severe morbidity, except for women with severe hypertensive disorder who were less likely to breastfeed either partially or exclusively at 6 to 8 weeks post-partum. Rather, breastfeeding outcomes were related to multi-dimensional factors including sociodemographic (age, ethnicity, living arrangement), other pregnancy outcomes (neonatal intensive care unit admission, mode of birth, women's perceived control during birth) and post-natal psychological factors (depressive symptoms). Women who experience severe maternal morbidity can be reassured that establishing successful breastfeeding can be achieved. More studies are required to understand what support is best for women who have complex health/social needs to establish breastfeeding.

Claiming an Ethic of Care for midwifery

Background:

The public domain of midwifery practice, represented by the educational and hospital institutions could be blamed for a subconscious ethical dilemma for midwifery practitioners. The result of such tension can be seen in complaints from maternity service users of dehumanised care. When expectations are not met, women report dehumanising experiences that carry long term consequences to both them and their child.

Objectives:

To revisit the ethical foundation of midwifery practice to reflect the feminist Ethic of Care and reframe what is valuable to women and midwives during the childbirth experience.

Research Design:

A comprehensive literature review is presented from the midwifery and feminist ethics discourse.

Ethical Considerations:

Nil to report.

Findings:

Women are vulnerable during childbirth as they need care, yet they prioritise elements of relationship in their experience. The Ethic of Care approach equalises the relationship between the midwife and the woman, providing the space for relationship building and allowing midwives to meet the expectations of their accepted responsibility.

Discussion:

Some midwives manage to balance the demands of the institution with the needs of the woman. This is described as both an emotional and professionally challenging balancing act.

Conclusion:

Until there is a formal acknowledgement of the different ethical approach to midwifery practice from within the profession and the Institution, midwifery identity and practice will continue to be compromised.

The relationship between severe maternal morbidity and psychological health symptoms at 6-8 weeks postpartum: a prospective cohort study in one English maternity unit

BACKGROUND

The incidence of severe maternal morbidity is increasing in high-income countries. However, little has been known about the impact on postnatal morbidity, particularly on psychological health outcomes. The objective of this study was to assess the relationship between severe maternal morbidity (ie. major obstetric haemorrhage, severe hypertensive disorders or intensive care unit/obstetric high dependency unit admission) and postnatal psychological health symptoms, focusing on post-traumatic stress disorder (PTSD) symptoms at 6-8 weeks postpartum.

METHOD

A prospective cohort study was undertaken of women who gave birth over six months in 2010 in an inner city maternity unit in England. Primary outcomes were prevalence of PTSD symptoms namely: 1) intrusion and 2) avoidance as measured using the Impact of Event Scale at 6 - 8 weeks postpartum via a self-administered postal questionnaire. Secondary outcomes included probable depression. Data on incidence of severe maternal morbidity were extracted from maternity records. Multivariable logistic regression analysis examined the relationship between severe maternal morbidity and PTSD symptoms taking into account factors that might influence the relationship.

RESULTS

Of women eligible to participate (n=3509), 52% responded. Prevalence of a clinically significant level of intrusion and avoidance were 6.4% (n=114) and 8.4% (n=150) respectively. There was a higher risk of PTSD symptoms among women who experienced severe maternal morbidity compared with women who did not (adjusted OR = 2.11, 95%CI = 1.17-3.78 for intrusion; adjusted OR = 3.28, 95%CI = 2.01-5.36 for avoidance). Higher ratings of reported sense of control during labour/birth partially mediated the risk of PTSD symptoms. There were no statistically significant differences in the prevalence or severity of symptoms of depression.

CONCLUSION

This is one of the largest studies to date of PTSD symptoms among women who had recently given birth. Findings showed that an experience of severe maternal morbidity was independently associated with symptoms of PTSD. Individually tailored care that increases women's sense of control during labour may be a protective factor with further work required to promote effective interventions to prevent these symptoms. Findings have important implications for women's health and the content and organisation of maternity services during and after the birth.

Pregnancy, childbirth and motherhood: a meta-synthesis of the lived experiences of immigrant women

INTRODUCTION

pregnancy, childbirth and motherhood are natural processes that bring joy to individual women and families. However, for many migrant women, becoming a mother while attempting to settle in a new country where the culture is different, can be a challenge for them.

AIM

to identify and synthesise qualitative research studies that explore the perceptions of pregnancy, childbirth and motherhood, and lived experiences of migrant women in their new home country.

METHODS

the seven steps of Noblit and Hare׳s meta-ethnography was used to conduct the meta-synthesis. Searches for literature of qualitative studies were conducted in May and June 2013 using PubMed, CINAHL, Google Scholar and La Trobe University databases. Studies published in English addressing pregnancy, childbirth and motherhood experiences of women from immigrant backgrounds met the inclusion criteria.

FINDINGS

15 studies published between 2003 and 2013 related to the pregnancy, childbirth and motherhood experiences for women from migrant backgrounds were eligible for the meta-synthesis. Four major themes were identified as common in all the qualitative studies: expectations of pregnancy and childbirth; experiences of motherhood; encountering confusion and conflict with beliefs; and dealing with migration challenges.

CONCLUSIONS

migrant women׳s pregnancy, childbirth and motherhood experiences are influenced by societal and cultural values, and they vary depending on the adjustment process in the new home country. The provision of culturally sensitive maternal health services enhances positive outcomes of a healthy mother and healthy infant. Supportive structures that address the issue of language and cultural barriers seem to promote antenatal clinic attendance, prevent pregnancy and childbirth complications, and enhance their positive motherhood experiences.

IMPLICATIONS

women from immigrant backgrounds have the right to receive adequate and sensitive health care during the childbearing and childrearing times regardless of their migrant status.

The transition from clinician to academic in nursing and allied health: a qualitative meta-synthesis

OBJECTIVES

The meta-synthesis provides a collective qualitative understanding of the transition experience from nursing and allied health clinician to academic. This understanding assists the preparation for those making the transition as well as giving guidance to those who have recently commenced in academia.

DESIGN

Published qualitative studies about the transition from clinician to academic were systematically selected in order to integrate their findings in a meta-synthesis.

DATA SOURCES

Databases searched were CINAHL, EMBASE, MEDLINE, SCOPUS, 'Education Research Complete', and 'Academic Search Premier'.

REVIEW METHODS

The search terms used were academ* OR facult* AND transition. The search was further refined by adding the terms qualitative AND clinic* OR practit* OR profession*. Studies were appraised for credibility, neutrality and relevance. Findings along with direct quotes were extracted from the studies and thematic analysis was used within an interpretative framework.

RESULTS

Seven studies were included in the meta-synthesis. The included studies were from nursing, physiotherapy, health and social care. The central theme was a shift in identity from clinician to academic which involved a progression through 4 phases over a period of 1- 3years. These phases were; 'feeling new and vulnerable'; 'encountering the unexpected'; 'doing things differently' and 'evolving into an academic'.

CONCLUSION

New academics felt unsettled and uncertain in the initial phases of transition. It is proposed that these challenges are related to difficulty extracting tacit knowledge and immersion in a new culture. The change of values and beliefs to adapt to the new culture require a concurrent identity shift which can take up to three years. Newcomers need collegial and institutional guidance with prioritization of tasks to address the multiplicity of the academic role and avoid frustration and disillusionment.

Commonalities and differences in infant feeding attitudes and practices in the context of HIV in sub-Saharan Africa: a metasynthesis

Exclusive breastfeeding (EBF) has been identified as a key intervention to promote infant health and to reduce the vertical transmission of HIV. Despite this knowledge and increased resources to promote EBF, the practice in sub-Saharan Africa (SSA) remains low among HIV+ women. Although a number of qualitative studies have been conducted throughout SSA, the influences on and consequences of infant feeding choices of HIV+ mothers' findings have not been regarded systematically. Therefore, our objective was to identify overarching themes, commonalities, and differences in infant feeding choices among qualitative studies with HIV+ mothers in SSA. Sixteen qualitative studies of infant feeding practices in the context of HIV were identified. Noblit and Hare's seven-step metasynthesis methodology was used to analyze the experiences of HIV+ women and those who provide infant feeding services/counseling. Data were available from approximately 920 participants (i.e., 750 HIV+ mothers, 109 health-care providers, and 62 family members) across 13 SSA countries from 2000 to 2011. From these data, five themes emerged within which 3-4 overarching key metaphors were identified. The consistency of key metaphors across a variety of geographic, economic, and cultural settings suggest the importance of approaching infant feeding holistically, within the context of maternal knowledge, health-care support, family resources, and cultural expectations. EBF campaigns in SSA are more likely to successfully support optimal health for infants and a safe supportive environment for their mothers when the impact of infant feeding decisions are evaluated across these themes.

Trauma-Informed Care With Childhood Maltreatment Survivors: What Do Maternity Professionals Want to Learn?

BACKGROUND: Posttraumatic stress disorder (PTSD) affects 8% of pregnant women, and the biggest risk factor for pregnancy PTSD is childhood maltreatment. The care they receive can lead to positive outcomes or to retraumatization and increased morbidity. The purpose of this study is to gather information from a range of clinicians about their continuing education needs to provide perinatal care to women with a maltreatment history and PTSD.

METHOD: Maternity health care professionals were interviewed by telephone. Network sampling and purposive sampling were used to include physicians, nurse practitioners, midwives, nurses, and doulas (n = 20), and results were derived from content analysis.

RESULTS: Most providers received little or no training on the issue of caring for women with a history of childhood maltreatment or PTSD during their original education but find working with this type of patient rewarding and wish to learn how to provide better care. Providers identified a range of educational needs and recommend offering a range of formats and time options for learning.

CONCLUSIONS: Maternity health care providers desire to work effectively with survivor moms and want to learn best practices for doing so. Thus, educational programming addressing provider needs and preferences should be developed and tested to improve care experiences and pregnancy outcomes for women with a history of trauma or PTSD.

A meta-ethnography of patients’ experience of chronic non-malignant musculoskeletal pain

Background

The alleviation of pain is a key aim of health care yet pain can often remain a puzzle as it is not always explained by a specific pathology. Musculoskeletal (MSK) pain is one of the most predominant kinds of chronic pain and its prevalence is increasing. One of the aims of qualitative research in health care is to understand the experience of illness, and make sense of the complex processes involved. However, the proliferation of qualitative studies can make it difficult to use this knowledge. There has been no attempt to systematically review and integrate the findings of qualitative research in order to increase our understanding of chronic MSK pain. A synthesis of qualitative research would help us to understand what it is like to have chronic MSK pain. Specifically, it would help us understand peoples' experience of health care with the aim of improving it.

Aim

The aim of this study was to increase our understanding of patients’ experience of chronic non-malignant MSK pain; utilise existing research knowledge to improve understanding and, thus, best practice in patient care; and contribute to the development of methods for qualitative research synthesis.

Methods

We used the methods of meta-ethnography, which aim to develop concepts that help us to understand a particular experience, by synthesising research findings. We searched six electronic bibliographic databases (including MEDLINE, EMBASE and PsycINFO) and included studies up until the final search in February 2012. We also hand-searched particular journals known to report qualitative studies and searched reference lists of all relevant qualitative studies for further potential studies. We appraised each study to decide whether or not to include it. The full texts of 321 potentially relevant studies were screened, of which 77 qualitative studies that explored adults’ experience of chronic non-malignant MSK pain were included. Twenty-eight of these studies explored the experience of fibromyalgia.

Results

Our findings revealed the new concept of an adversarial struggle that explains the experience of people with chronic MSK pain. This included the struggle to affirm self and construct self over time; find an explanation for pain; negotiate the health-care system while feeling compelled to stay in it; be valued and believed; and find the right balance between sick/well and hiding/showing pain. In spite of this struggle, our model showed that some people were able to move forward alongside their pain by listening to their body rather than fighting it; letting go of the old self and finding a new self; becoming part of a community and not feeling like the only one; telling others about pain and redefining relationships; realising that pain is here to stay rather than focusing on diagnosis and cure; and becoming the expert and making choices. We offer unique methodological innovations for meta-ethnography, which allowed us to develop a conceptual model that is grounded in 77 original studies. In particular, we describe a collaborative approach to interpreting the primary studies.

Conclusion

Our model helps us to understand the experience of people with chronic MSK pain as a constant adversarial struggle. This may distinguish it from other types of pain. This study opens up possibilities for therapies that aim to help a person to move forward alongside pain. Our findings call on us to challenge some of the cultural notions about illness, in particular the expectation of achieving a diagnosis and cure. Cultural expectations are deep-rooted and can deeply affect the experience of pain. We therefore should incorporate cultural categories into our understanding of pain. Not feeling believed can have an impact on a person’s participation in everyday life. The qualitative studies in this meta-ethnography revealed that people with chronic MSK pain still do not feel believed. This has clear implications for clinical practice. Our model suggests that central to the relationship between patient and practitioner is the recognition of the patient as a person whose life has been deeply changed by pain. Listening to a person’s narratives can help us to understand the impact of pain. Our model suggests that feeling valued is not simply an adjunct to the therapy, but central to it. Further conceptual syntheses would help us make qualitative research accessible to a wider relevant audience. Further primary qualitative research focusing on reconciling acceptance with moving forward with pain might help us to further understand the experience of pain. Our study highlights the need for research to explore educational strategies aimed at improving patients’ and clinicians’ experience of care.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Nurses' perspectives on the intersection of safety and informed decision making in maternity care

OBJECTIVE

To explore maternity nurses' perceptions of women's informed decision making during labor and birth to better understand how interdisciplinary communication challenges might affect patient safety.

DESIGN

Constructivist grounded theory.

SETTING

Four hospitals in the western United States.

PARTICIPANTS

Forty-six (46) nurses and physicians practicing in maternity units.

METHOD

Data collection strategies included individual interviews and participant observation. Data were analyzed using the constant comparative method, dimensional analysis, and situational analysis (Charmaz, 2006; Clarke, 2005; Schatzman, 1991).

RESULTS

The nurses' central action of holding off harm encompassed three communication strategies: persuading agreement, managing information, and coaching of mothers and physicians. These strategies were executed in a complex, hierarchical context characterized by varied practice patterns and relationships. Nurses' priorities and patient safety goals were sometimes misaligned with those of physicians, resulting in potentially unsafe communication.

CONCLUSIONS

The communication strategies nurses employed resulted in intended and unintended consequences with safety implications for mothers and providers and had the potential to trap women in the middle of interprofessional conflicts and differences of opinion.

Giving birth with epidural analgesia: the experience of first-time mothers

The purpose of our qualitative descriptive study was to describe the birth experiences of women using epidural analgesia for pain management. We interviewed nine primiparas who experienced vaginal births. Five themes emerged: (a) coping with pain, (b) finding epidural administration uneventful, (c) feeling relief having an epidural, (d) experiencing joy, and (e) having unsettled feelings of ambivalence. Although epidural analgesia was found to be effective for pain relief and may contribute to some women's satisfaction with the birth experience, it does not guarantee a quality birth experience. In order to support and promote childbearing women's decision making, we recommend improved education on the variety of available pain management options, including their risks and benefits. Fostering a sense of caring, connection, and control in women is a key factor to ensure positive birth experiences, regardless of pain management method.

Lifelong significance of disempowering experiences in prenatal and maternity care: interviews with elderly Swedish women

In this article I show how the effects of harsh and humiliating treatment, experienced by a number of Swedish women in antenatal care and childbirth in the mid-20th Century, endured for the rest of their lives. This treatment was carried out by medical staff in conformity with a view of expectant mothers as irresponsible and ignorant and with the prevalent idea of "natural birth." These effects were findings in an interview investigation that, with a colleague, I conducted into paid and unpaid work and health of 20 women, seen in a lifetime perspective. Our biomedical way of understanding risks and complications during pregnancy and birthing was confronted with many participants' feelings of distress, guilt, and grief linked to their childbearing experience. I interpret the treatments as "violations of dignity" and as abuse. The consequences are similar to those following traumatic birth experiences described in today's literature.

A metasynthesis of midwife-led care

The purpose of this metasynthesis is to describe and interpret qualitative research relating to midwife-led care to see if it sheds light on why low-risk women experience fewer birth interventions within this model of care. Eleven articles were included in the review. Three themes emerged: (a) relationally mediated benefits for women that resulted in increased agency and empathic care; (b) the problematic interface of midwife-led units with host maternity units, stemming from a clash of models and culture; and (c) greater agency for midwives within midwife-led models of care though bounded by the relationship with the host maternity unit. This metasynthesis suggests that lower rates of interventions could be linked to the greater agency experienced by women and midwives within midwife-led models, and that these effects are mediated, in part, by the smallness of scale in these settings.

No longer pregnant, not yet a mother: giving birth prematurely to a very-low-birth-weight baby

In this article we present the findings of a qualitative examination of 30 mothers of very-low-birth-weight babies. Interviews conducted with the mothers when the babies were still in neonatal hospitalization show that virtually all the mothers described their delivery both as a traumatic event, and as a nonevent in which they felt that they barely participated. Most of them blamed themselves for not carrying full term, some blamed others, and some believed the premature delivery saved their baby's life. Following their truncated pregnancies, their "nonparticipation" in the delivery, and their separation from their newborn immediately after the delivery, virtually all the women reported difficulty grasping that they were mothers. Many reported a sense of loss, emptiness, and frustration that the baby was no longer inside. The women took a variety of measures, including magical means and parenting behaviors, to safeguard their vulnerable babies and to become mothers within the constraints of the neonatal unit.