Childbirth experience in women participating in a continuity of midwifery care project

BackgroundContinuity models of care are rare in Sweden, despite the evidence of their benefit to women and babies. Previous studies have shown certain factors are associated with a positive birth experience, including continuity of midwifery care.AimThe aim was to investigate women's childbirth experiences in relation to background data, birth outcome and continuity with a known midwife, in a rural area of Sweden.MethodsAn experimental cohort study. Participating women were offered continuity of midwifery care in pregnancy and birth, during selected time periods. Data were collected in mid-pregnancy and two months after birth. The Childbirth Experience Questionnaire was used to determine women's birth experiences.ResultA total of 226 women responded to the follow-up questionnaire. Not living with a partner, fear of giving birth, and a birth preference other than vaginal were associated with a less positive birth experience. Having had a vaginal birth with no epidural, no augmentation and no birth complication all yield a better birth experience. Women who had had a known midwife were more likely to have had a positive birth experience overall, predominantly in the domain Professional support.ConclusionsThe results of this study showed that women who received care from a known midwife in labour were more likely to have a positive birth experience. The results also pointed out the benefits of a less medicalized birth as important for a good birth experience, and that some women may need extra support to avoid a less positive birth experience.     

Documenting risk: A comparison of policy and information pamphlets for using epidural or water in labour

BackgroundApproximately 30% of Australian women use epidural analgesia for pain relief in labour, and its use is increasing. While epidural analgesia is considered a safe option from an anaesthetic point of view, its use transfers a labouring woman out of the category of ‘normal’ labour and increases her risk of intervention. Judicious use of epidural may be beneficial in particular situations, but its current common use needs to be assessed more closely. This has not yet been explored in the Australian context.AimTo examine personal, social, institutional and cultural influences on women in their decision to use epidural analgesia in labour. Examining this one event in depth illuminates other birth practices, which can also be analysed according to how they fit within prevailing cultural beliefs about birth.MethodsEthnography, underpinned by a critical medical anthropology methodology.ResultsThese findings describe the influence of risk culture on labour ward practice; specifically, the policies and practices surrounding the use of epidural analgesia are contrasted with those on the use of water. Engaging with current risk theory, we identify the role of power in conceptualisations of risk, which are commonly perpetuated by authority rather than evidence.ConclusionsAs we move towards a risk-driven society, it is vital to identify both the conception and the consequences of promulgations of risk. The construction of waterbirth as a ‘risky’ practice had the effect of limiting midwifery practice and women's choices, despite evidence that points to the epidural as the more ‘dangerous’ option.     

Regardless of where they give birth,women living in non-metropolitan areas are less likely to have an epidural than their metropolitan counterparts

QuestionCan differences in Australian birth intervention rates be explained by women's residence at the time of childbearing?.MethodsData were collected prospectively via surveys in 1996, 2000, 2003, 2006 and 2009 from women, born between 1973 and 1978, of the Australian Longitudinal Study on Women's Health. Analysis included data from 5886 women who had given birth to their first child between 1994 and 2009. Outcome measures were self-report of birth interventions: pharmacological pain relief (epidural and spinal block analgesia, inhalational analgesia and intramuscular injections), surgical births (an elective or emergency caesarean section) and instrumental births (forceps and ventouse).FindingsPrimiparous women residing in non-metropolitan areas of Australia experienced fewer birth interventions than women residing in metropolitan areas: 43% versus 56% received epidural analgesia; 8% versus 11% had elective caesarean sections; and 16% versus 18% had emergency caesarean sections. Differences in maternal age and private health insurance status at first birth accounted for differences in surgical birth rates but did not fully explain differences in epidural analgesia.ConclusionNon-metropolitan women had fewer birth interventions, particularly epidural analgesia, than metropolitan women. Differences in maternal age and private health insurance do not fully explain the differences in epidural analgesia rates, suggesting care provided to labouring women may differ by area of residence. The difference in epidural analgesia rates may be due to lack of choice in maternity services, however it could also be due to differing expectations leading to differences in birth interventions for primiparous women living in metropolitan and non-metropolitan areas.     

Women's birth expectations,are they fulfilled? Findings from a longitudinal Swedish cohort study

BackgroundThe importance of women's expectations on the experience of birth has shown contradictory results regarding fulfilment. The aim of this study was to describe pregnant women's expectations of birth and to investigate if these expectations were fulfilled. An additional aim was to determine if unfulfilled expectations were related to the mode of birth, use of epidural and the birth experience.MethodsThis research investigated a prospective regional cohort study of 1042 Swedish-speaking women who completed a questionnaire about birth expectations in late pregnancy and were followed up with two months after birth. Five areas were under study: support from partner, support from midwife, control, participation in decision making and the midwife's presence during labour and birth. An index combining expectations and experiences was created.ResultsCertain background characteristics were associated with expectations as well as experiences. Statistically significant differences were shown between expectations and experiences in support from midwife (mean 3.41 vs 3.32), support from partner (mean 3.70 vs 3.77), and midwife's presence (mean 3.00 vs 3.39). Experiences ‘worse than expected’ regarding decision making and control were associated with modes of birth other than vaginal and four out of five areas were associated with a less positive birth experience.ConclusionSome women had high birth expectations of which some were fulfilled. An expectation on support from the midwife was less likely to be achieved, while support from partner and the midwives’ presence were fulfilled. If the woman's expectations were not fulfilled, e.g. became ‘worse than expected’ this was associated with a less positive overall birth experience as well as with instrumental or surgical mode of birth.     

Epidural analgesia during birth and adverse neonatal outcomes: A population-based cohort study

BackgroundIn general, epidural analgesia is considered a safe and efficient way to relieve pain during active labour and is increasingly used in childbirth. It is well documented that epidural analgesia during birth has benefits but also adverse effects. However, evidence is limited on how epidural analgesia influences neonatal outcome in a low-risk population of birthing women.AimTo examine low Apgar score, foetal hypoxia and admission to the neonatal intensive care unit in neonates of low-risk women receiving epidural analgesia during birth.MethodsA cohort study using registry data to investigate a population of 23,272 low-risk women giving birth at a university hospital.ResultsEpidural analgesia was used in 21.6% of low-risk women during birth. Low Apgar score, foetal hypoxia, and admission to the neonatal intensive care unit were found in 0.6%, 0.6%, and 10.0%, respectively in neonates of mothers receiving epidural analgesia during birth compared to 0.3%, 0.6%, and 5.6%, respectively in the non-exposed group. Epidural analgesia was associated with low Apgar score, adjusted odds ratio 1.76 (95% CI 1.07–2.90) and admission to the neonatal intensive care unit, adjusted odds ratio 1.43 (95% CI 1.26–1.62). A mediation analysis indicates the impact of epidural analgesia on adverse neonatal outcomes was mediated by obstetric complications like maternal fever, labour augmentation, and foetal malpresentation.ConclusionThis study found use of epidural analgesia during birth in low-risk pregnant women was associated with infant low Apgar score and admission to the neonatal intensive care unit.     

Taking the reins: A grounded theory study of women's experiences of negotiating water immersion for labour and birth after a previous caesarean section

BackgroundWomen seeking a vaginal birth after a caesarean section (VBAC) frequently want to keep their subsequent labour and birth free from intervention. Water immersion (WI) during labour is potentially an effective tool for women having a VBAC for its natural pain-relieving properties. However, negotiating access to WI can be difficult, especially in the context of VBAC.AimTo explore women's experiences of negotiating WI for labour and birth in the context of VBAC.MethodologyThis Grounded Theory study followed Strauss and Corbin's framework and analytic process. Twenty-five women planning or using WI for their VBAC labour or birth were recruited from two midwifery practices and a social media group across Australia. Participants were interviewed during pregnancy and/or postnatally.Findings‘Taking the reins’, the core category explaining the women’s experiences of assuming authority over their birth, comprised five categories: ‘Robbed of my previous birth experience’; ‘My eyes were opened’; ‘Water is my tool for a successful VBAC’; ‘Actioning my choices and rights for WI’, and ‘Empowered to take back control’. ‘Wanting natural and normal’ was the driving force behind women’s desire to birth vaginally. Two mediating factors: Having someone in your corner and Rules for birth facilitated or hindered their birth choices, respectively.ConclusionThe women became active participants in their healthcare by seeking information and options to keep their birth experience natural and normal. Support from other women and advocacy in the form of continuity of midwifery care was crucial in successfully negotiating WI for their VBAC when navigating the complex health system.     

Evaluation of a regional midwifery caseload model of care integrated across five birthing sites in South Australia: Women’s experiences and birth outcomes

IntroductionThe ongoing closure of regional maternity services in Australia has significant consequences for women and communities. In South Australia, a regional midwifery model of care servicing five birthing sites was piloted with the aim of bringing sustainable birthing services to the area. An independent evaluation was undertaken. This paper reports on women’s experiences and birth outcomes.AimTo evaluate the effectiveness, acceptability, continuity of care and birth outcomes of women utilising the new midwifery model of care.MethodAn anonymous questionnaire incorporating validated surveys and key questions from the Quality Maternal and Newborn Care (QMNC) Framework was used to assess care across the antenatal, intrapartum and postnatal period. Selected key labour and birth outcome indicators as reported by the sites to government perinatal data collections were included.FindingsThe response rate was 52.6% (205/390). Women were overwhelmingly positive about the care they received during pregnancy, birth and the postnatal period. About half of women had caseload midwives as their main antenatal care provider; the other half experienced shared care with local general practitioners and caseload midwives. Most women (81.4%) had a known midwife at their birth. Women averaged 4 post-natal home visits with their midwife and 77.5% were breastfeeding at 6–8 weeks. Ninety-five percent of women would seek this model again and recommend it to a friend. Maternity indicators demonstrated a lower induction rate compared to state averages, a high primiparous normal birth rate (73.8%) and good clinical outcomes.ConclusionThis innovative model of care was embraced by women in regional SA and labour and birth outcomes were good as compared with state-wide indicators.     

Women's expectations and experiences with labour pain in medical and midwifery models of birth in the United States

BackgroundThis research focuses on how women understand and experience labour as related to two competing views of childbirth pain. The biomedical view is that labour pain is abnormal and anaesthesia/analgesia use is encouraged to relieve the pain. The midwifery view is that pain is a normal part of labour that should be worked with instead of against.AimsTo determine differences in the preparation for and experiences with labour pain by women choosing midwives versus obstetricians.MethodsPrenatal and postpartum in-depth semi-structured interviews were conducted with a convenience sample of 80 women in Florida (United States): 40 who had chosen an obstetrician and 40 who had chosen a licensed midwife as their birth practitioner.FindingsWomen in both groups were concerned with the pain of childbirth before and after their labour experiences. Women choosing midwives discussed preparing for pain through various non-pharmaceutical coping methods, while women choosing physicians discussed pharmaceutical and non-pharmaceutical pain relief.ConclusionsEqual numbers of women expressed concerns with childbirth pain during the prenatal interviews, while more women choosing doctors spoke about pain after their births. Women had negative experiences when their planned pain relief method, either natural or medical, did not occur. The quandary facing women when it comes to labour pain relief is not choosing what they desire, but rather preparing themselves for the possibility that they may have to accept alternatives to their original preferences.     

Epidurals during normal labour and birth — Midwives’ attitudes and experiences

BackgroundMidwives have their own beliefs and values regarding pain during childbirth. Their preferences concerning labour pain management may influence women’s choices.AimTo gain a deeper understanding of midwives’ attitudes and experiences regarding the use of an epidural during normal labour.MethodsA qualitative approach was chosen for data collection. Ten in-depth interviews were conducted with midwives working in three different obstetric units in Norway. The transcribed interviews were analysed using Malterud’s systematic text condensation.FindingsThe analysis provided two main themes: “Normal childbirth as the goal” and “Challenges to the practice, knowledge, philosophy and experience of midwives”. Distinctive differences in experiences and attitudes were found. The workplace culture in the obstetric units affected the midwives’ attitudes and their midwifery practice. How they attended to women with epidural also differed. An epidural was often used as a substitute for continuous support when the obstetric unit was busy.DiscussionMidwives estimate labour pain differently, and this might impact the midwifery care. However, midwives’ interests and preferences concerning labour pain management should not influence women’s choices. Midwives are affected by the setting where they work, and research highlights that an epidural might lead to a focus on medical procedures instead of the normality of labour.ConclusionMidwives should be aware of how powerful their position is and how the workplace culture might influence their attitudes. The focus should be on “working with” women to promote a normal birth process, even with an epidural.     

Japanese women's experiences of pharmacological pain relief in New Zealand

BackgroundIn Japan, most women manage labour pain without pharmacological interventions. However, New Zealand statistics show a high percentage of epidural use amongst Asian women. Entonox (a gas mixture of nitrous oxide and oxygen) and pethidine are also available to women in New Zealand. This article investigates how Japanese women in New Zealand respond to the use of pharmacological pain relief in labour.QuestionsThe study was guided by two research questions: (1) How do Japanese women experience and manage labour pain in New Zealand? (2) How do they feel about the use of pharmacological pain relief?MethodsThirteen Japanese women who had given birth in New Zealand were interviewed individually or in a focus group. The conversations were analysed using thematic analysis.FindingsAlthough in Japan very few women use pain relief, nine women received epidural and/or Entonox out of 11 women who experienced labour pain. The contrast between their Japanese cultural expectations and their birth experiences caused some of the women subsequent personal conflict.ConclusionJapanese women's cultural perspectives and passive attitudes were demonstrated to influence the decision-making process concerning pain relief. It was concluded that understanding Japanese cultural worldviews and approaches to the role of pain in labour would help maternity providers in their provision of appropriate care for Japanese women.     

Learning to be a midwife: Midwifery students’ experiences of an extended placement within a midwifery group practice

AimTo investigate the experiences, perspectives and plans of students who had a six-month placement with the midwifery group practice.MethodsFocus groups were conducted with fifteen third – year Bachelor of Midwifery students who had undertaken an extended placement at a midwifery group practice in a large tertiary referral hospital in Queensland, Australia.ResultsFour main themes were identified in the data: Expectations of the Placement; Facilitating learning within a midwifery group practice model; Transitioning between models of care and Philosophy and culture of midwifery group practice.Discussion and conclusionThird-year midwifery students valued the experience of working one-on-one for an extended placement with a midwife providing continuity of care within a caseload model. The experience was the highlight of their degree and they learned ‘how to be a midwife’. Most students found reintegrating back into the hospital system of care challenging, reporting that their developed skills of supporting women holistically and facilitating normal birth were not fully utilised when returning to the task-orientated birth suite. Students valued thoughtful, kind and supportive midwifery preceptors who supported them to transition back into the hospital.Implications and recommendationsUndertaking an extended placement within a midwifery group practice provides students with a rich and holistic learning experience and helps them develop a sense of professional identity. Student placements situated within models of care which provide continuity of midwifery care should be proactively enabled by health services and universities. Research of the longer-term impacts of an extended midwifery group practice clinical placement on midwifery graduates’ capabilities and competencies 3–5 years post registration should be conducted.     

‘They follow the wants and needs of an institution’: Midwives’ views of water immersion

BackgroundA midwife’s ability to fully support women’s autonomy and self-determination with respect to midwifery care is often challenging. This is particularly true of water immersion for labour and birth. However, the woman’s agency over what happens to her body and that of her unborn baby should be key considerations for maternity care provision.ObjectivesA three phased mixed-methods study was undertaken to examine how water immersion policies and guidelines are informed. Phase three of this study captured the knowledge and experiences of Australian midwives, their support for water immersion and their experiences of using policies and guidelines to inform and facilitate the practice.MethodsCritical, post structural, interpretive interactionism was used to examine more than 300 responses to three open-ended questions included in a survey of 233 midwives. Comment data were analysed to provide further insight, context and meaning to previously reported results.FindingsFindings demonstrated a complex, multidimensional interplay of factors that impacted on both the midwife’s ability to offer and the woman’s decision to use water immersion under the themes ‘the reality of the system’, ‘the authoritative ‘others’’ and ‘the pseudo decision-makers’. Multiple scaffolded levels were identified, each influenced by the wider macro-socio-political landscape of Australian midwifery care.ConclusionsThe insight gained from examining midwives’ views and opinions of water for labour and birth, has aided in contextualising previously reported results. Such insight highlights the importance of qualitative research in challenging the status quo and working towards woman-centred practice and policy.     

Functional discomfort and a shift in midwifery paradigm

ObjectiveTo determine and critically examine maternity attitudes surrounding labour pain and how midwives can best facilitate women navigating intrapartum discomfort without relying on ‘pain-relief’ strategies or immediate recourse for analgesic assistance.ApproachThis article examines current literature using seminal research and wider international perspectives, exploring the complex and fluctuating needs of women negotiating the composite factors of labour discomfort are investigated.FindingsFactors such as birth environment, fear, midwifery presence, and self-efficacy, have a significant impact on the uptake of intrapartum analgesia. A holistic view of intrapartum discomfort is needed to shift the current paradigm of pathologising labour pain into one which situates it as a source of positive physiology and functional discomfort.ConclusionContinuing to practice with a pharmacological outlook, aiming to rid the labouring body of discomfort, is reductionist for both midwives and women. Midwives must seek to employ a new lexicon with which to communicate and facilitate women within the dynamic and continually changing territory of labour. If this conceptual shift is realised, the subsequent positive sequalae of women rediscovering their innate birthing capabilities could create a situation where birth can be considered as an aesthetic peak experience, improving satisfaction on both sides of the midwife-mother diad.     

Women’s reports of satisfaction and respect with continuity of care experiences by students: Findings from a routine,online survey

BackgroundPre-registration midwifery students in Australia undertake a minimum of ten continuity of care experiences with childbearing women. However, women are rarely asked to formally evaluate this care by students.AimTo evaluate data from a routine, web-based survey of women about having a midwifery student provide a continuity of care experience.MethodsAll women (n = 886) recruited by a midwifery student for a continuity of care experience during a 12 month period received an email inviting them to complete an online survey. The survey included personal details, experiences of care, and two scales on Respect and Satisfaction.ResultsA response rate of 57% (n = 501) was achieved. On average students attended six antenatal visits (mean = 5.83) and had six postnatal contacts with women. Most students attended labour and birth (92.6% n = 464). Most women rated overall satisfaction with care by their student as ‘better than they had hoped’. Positive correlations were found between number of antenatal visits and postnatal contact with students on both levels of satisfaction and respect felt by women. Women felt more satisfied when their midwifery student attended labour and birth.ConclusionsThe online survey was feasible and provided valid and reliable feedback from women about their student during a continuity of care experience. Women valued having an ongoing relationship with a student during pregnancy, labour and birth, and postpartum. Pre-registration midwifery education programs should continue to privilege relationship-based care and national standards should support the effective integration of continuity of care experiences.     

A qualitative study of how caseload midwifery is experienced by couples in Denmark

Background

Caseload midwifery is expanding in Denmark. There is a need for elaborating in-depth, how caseload midwifery influences the partner and the woman during childbirth and how this model of care influences the early phases of labour.

Women's satisfaction with antenatal care: Comparing women in Sweden and Australia

BackgroundSatisfaction with antenatal care could differ depending on the organisation and the context of care.AimTo compare antenatal care in Australia and Sweden, to identify deficiencies in the content of antenatal care and what aspects contributed most in dissatisfaction with antenatal care.MethodsA longitudinal survey of 123 Australian and 386 Swedish women recruited during one year in regional hospitals in Sweden and Australia. Data collected by three questionnaires.ResultsWomen in Australia had more antenatal visits, less continuity of midwife caregiver but were more satisfied with antenatal education and the emotional aspects of antenatal care. Although the overall satisfaction was high, deficiencies were found in more than half of the studied variables in the content of care. Women in Sweden were more dissatisfied with information about labour and birth (OR 3.1; 1.8–5.3) and information about the time following birth (OR 3.8; 2.2–6.3), but more satisfied with the involvement of the father (OR 0.3; 0.2–0.6). Factors that contributed most to dissatisfaction with antenatal care overall were deficiency in information about pregnancy related issues (OR 3.4; 1.3–8.7) and not being taken seriously by the midwife (OR 4.1; 1.6–10.1).ConclusionSatisfaction with antenatal care was high in both groups of women. Australian women were more satisfied than the Swedish women with the emotional aspects of care. Deficiencies were found in more than half of the variables measured relating to the specific aspects of care. Lack of information and not being treated seriously were important factors for not being satisfied.