Birth environments for women with complex pregnancies: A mixed-methods systematic review

BackgroundBirth environments can help support women through labour and birth. Home-like rooms which encourage active birthing are embraced in midwifery-led settings. However, this is often not reflected in obstetric settings for women with more complex pregnancies.AimTo investigate the impact of the birth environment for women with complex pregnancies.MethodsThis was a mixed-methods systematic review, incorporating qualitative and quantitative research. A literature search was implemented across three databases (Medline, CINAHL, Embase) from the year 2000 to June 2021. Studies were eligible if they were based in an Organisation for Economic Cooperation and Development country and reported on birth environments for women with complex pregnancies. Papers were screened and quality appraised by two researchers independently.Findings30,345 records were returned, with 15 articles meeting inclusion criteria. Studies were based in Australia, the UK, and the USA. Participants included women and health professionals. Five main themes arose: Quality of care and experience; Supportive spaces for women; Supportive spaces for midwives; Control of the space; Design issues.DiscussionWomen and midwives found the birth environment important in supporting, or failing to support, a positive birth experience. Obstetric environments are complex spaces requiring balance between space for women to mobilise and access birthing aids, with the need for medical teams to have easy access to the woman and equipment in emergencies.ConclusionFurther research is needed investigating different users’ needs from the environment and how safety features can be balanced with comfort to provide high-quality care and positive experiences for women.     

Uncovered and disrespected. A qualitative study of Jordanian women’s experience of privacy in birth

BackgroundPrivacy is related to a person’s sense of self and the need to be respected and it is a key factor that contributes to women’s satisfaction with their birth experiences.AimTo examine the meaning of privacy for Jordanian women during labour and birth.MethodA qualitative interpretive design was used. Data were collected through face-to-face semi-structured interviews with 27 Jordanian women. Of these women, 20 were living in Jordan while seven were living in Australia (with birthing experience in both Jordan and Australia). Thematic analysis was used to analyse the data.ResultsThe phrase ‘there is no privacy’ captured women’s experience of birth in Jordanian public hospitals and in some private hospital settings. Women in public hospitals in Jordan had to share a room during their labour with no screening. This experience meant that they were, “lying there for everyone to see”, “not even covered by a sheet” and with doctors and others coming in and out of their room. This experience contrasted with birth experienced in Australia.ConclusionsThis study explicates the meaning of privacy to Jordanian women and demonstrates the impact of the lack of privacy during labour and birth. Seeking a birth in a private hospital in Jordan was one of the strategies that women used to gain privacy, although this was not always achieved. Some strategies were identified to facilitate privacy, such as being covered by a sheet; however, even simple practices are difficult to change in a patriarchal, medically dominated maternity system.     

Born in another country: Women's experience of labour and birth in Queensland,Australia

BackgroundWomen born outside Australia make up more than a fifth of the Queensland birthing population and like migrants in other parts of the world face the challenges of cultural dislocation and possible language barriers. Recognising that labour and birth are major life events the aim was to investigate the experiences of these women in comparison to native-born English speaking women.MethodsSecondary analysis of data from a population based survey of women who had recently birthed in Queensland. Self-reported clinical outcomes and quality of interpersonal care of 481 women born outside Australia who spoke a language other than English at home were compared with those of 5569 Australian born women speaking only English.ResultsAfter adjustment for demographic factors and type of birthing facility, women born in another country were less likely to be induced, but more likely to have constant electronic fetal monitoring (EFM), to give birth lying on their back or side, and to have an episiotomy. Most women felt that they were treated as an individual and with kindness and respect. However, women born outside Australia were less likely to report being looked after ‘very well’ during labour and birth and to be more critical of some aspects of care.ConclusionIn comparing the labour and birth experiences of women born outside the country who spoke another language with native-born English speaking women, the present study presents a largely positive picture. However, there were some marked differences in both clinical and interpersonal aspects of care.     

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.     

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 and waterbirth: A systematic meta-synthesis of qualitative studies

BackgroundThe practice of waterbirth is increasing worldwide and has been a feature of maternity services in the United Kingdom for over twenty years. The body of literature surrounding the practice focusses on maternal and neonatal outcomes comparing birth in and out of water.AimTo undertake a review of qualitative studies exploring women’s experiences of waterbirth. This understanding is pertinent when supporting women who birth in water.MethodsA literature search was conducted in databases British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, Maternity and Infant Care, Medline, Applied Social Sciences Index and Abstracts and Web of Science, using search terms waterbirth, labour/labor, childbirth, women, mothers, experience, perception and maternity care. Five primary research articles published between 2003 and 2018 which explored the views of women who had birthed in water were selected for inclusion. Using meta-ethnography, qualitative research studies were analysed and synthesised using the method of ‘reciprocal translational analysis’ identifying themes relating to women’s experiences of birthing in water.FindingsFour themes were identified: women’s knowledge of waterbirth; women’s perception of physiological birth; water, autonomy and control; and waterbirth: easing the transition.Discussion and conclusionDespite the paucity of qualitative studies exploring women’s experiences of waterbirth, meta-synthesis of those that do exist suggested women identify positively with the choice. The experience of birthing in water appears to enhance a woman’s sense of autonomy and control during childbirth suggesting waterbirth can be an empowering experience for women who choose it.     

Does antenatal education affect labour and birth? A structured review of the literature

ObjectiveTo undertake a structured review of the literature to determine the effect of antenatal education on labour and birth, particularly normal birth.MethodOvid Medline, CINAHL, Cochrane and Web of Knowledge databases were searched to identify research articles published in English from 2000 to 2012, using specified search terms in a variety of combinations. All articles included in this structured review were assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).FindingsThe labour and birthing effects on women attending antenatal education may include less false labour admissions, more partner involvement, less anxiety but more labour interventions.ConclusionThis literature review has identified that antenatal education may have some positive effects on women's labour and birth including less false labour admissions, less anxiety and more partner involvement. There may also be some negative effects. Several studies found increased labour and birth interventions such as induction of labour and epidural use. There is contradictory evidence on the effect of antenatal education on mode of birth. More research is required to explore the impact of antenatal education on women's birthing outcomes.     

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.     

Caesarean section by country of birth in New South Wales,Australia

ObjectiveTo determine rates of caesarean section by country of birth and by obstetric risks.MethodsWe analysed the New South Wales Perinatal Data Collection data of women giving birth between January 2013 and December 2015. Obstetric risk was classified using the Robson’s 10-group classification. Multilevel logistic regression with a random intercept was used to measure the variation in caesarean section rate between immigrants from different countries and between regional immigrant groups.ResultsWe analysed data from 283,256 women, of whom 90,750 had a caesarean section (32.0%). A total of 100,120 women were born overseas (35.3%), and 33,028 (33.0%) had a caesarean section. The caesarean section rate among women from South and Central Asia ranged from 32.6% for women from Pakistan to 47.3% for women from Bangladesh. For South East Asia, women from Cambodia had the lowest caesarean section rate (19.5%) and women from Indonesia had the highest rate (37.3%). The caesarean section rate for North Africa and the Middle East ranged from 28.0% for women from Syria to 50.1% for women from Iran. Robson groups that accounted for most of the caesarean sections were women who had previous caesarean section (36.5%); nulliparous women, induced or caesarean section before labour (26.2%); and nulliparous women, spontaneous labour (8.9%).ConclusionsThe caesarean section rate varied significantly between women from different countries of birth within the same region. Women from some countries of birth had the higher caesarean section rates in some Robson groups.     

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.     

“I guess baby was just too comfy in there…”: A qualitative study of women's experiences of elective late-term induction of labour

BackgroundThe frequency of induction of labour (IOL) in late-term pregnancy has increased significantly, but little is known about how women with uncomplicated pregnancies experience IOL for late-term indication alone.AimTo explore how women with uncomplicated pregnancies experienced late-term IOL.MethodsQualitative interviews were conducted with 23 women who all had labour induced on late-term indication only. Participants were recruited from two Danish hospitals who offered an outpatient induction regime. The women were interviewed 4–8 weeks after birth. Data were analysed using thematic analysis.ResultsAll women had hoped for a spontaneous birth. Prolonged pregnancy was understood as the body/baby “not being ready”, but generally, the women were not worried at that point. Most women felt adequately informed about the reasons for IOL, but some requested more information and time to consider their options. The majority considered IOL to be both an offer and a recommendation. One-third of the participants were initially hesitant but chose/accepted IOL because of weariness from pregnancy and the impatience to deliver a healthy child. The opportunity of outpatient induction was generally appreciated as it allowed the women to continue everyday activities while waiting for labour to begin. Nineteen women reported having a good birthing experience. Two women felt that negative birthing experiences were partly related to IOL.ConclusionsMost women considered the late-term IOL to be a positive experience. Some women requested more information and time to consider alternatives. These women should be provided with supported opportunities to consider the options.     

‘I really needed help’: What mothers say about their post-birth care in Queensland,Australia

BackgroundAustralian mothers consistently rate postnatal care as the poorest aspect of their maternity care, and researchers and policymakers have widely acknowledged the need for improvement in how postnatal care is provided.AimTo identify and analyse mothers’ comments about postnatal care in their free text responses to an open ended question in the Having a Baby in Queensland Survey, 2010, and reflect on their implications for midwifery practice and maternity service policies.MethodsThe survey assessed mothers’ experiences of maternity care four months after birth. We analysed free-text data from an open-ended question inviting respondents to write ‘anything else you would like to tell us’. Of the final survey sample (N = 7193), 60% (N = 4310) provided comments, 26% (N = 1100) of which pertained to postnatal care. Analysis included the coding and enumeration of issues to identify the most common problems commented on by mothers. Comments were categorised according to whether they related to in-hospital or post-discharge care, and whether they were reported by women birthing in public or private birthing facilities.ResultsThe analysis revealed important differences in maternal experiences according to birthing sector: mothers birthing in public facilities were more likely to raise concerns about the quality and/or duration of their in-hospital stay than those in private facilities. Conversely, mothers who gave birth in private facilities were more likely to raise concerns about inadequate post-discharge care. Regardless of birthing sector, however, a substantial proportion of all mothers spontaneously raised concerns about their experiences of inadequate and/or inconsistent breastfeeding support.ConclusionWomen who birth in private facilities were more likely to spontaneously report concerns about their level of post-discharge care than women from public facilities in Queensland, and publically provided community based care is not sufficient to meet women's needs. Inadequate or inconsistent professional breastfeeding support remains a major issue for early parenting women regardless of birthing sector.     

Women’s experiences of decision-making and attitudes in relation to induction of labour: A survey study

BackgroundRates of induction of labour have been increasing globally to up to one in three pregnancies in many high-income countries. Although guidelines around induction, and strength of the underlying evidence, vary considerably by indication, shared decision-making is increasingly recognised as key. The aim of this study was to identify women’s mode of birth preferences and experiences of shared decision-making for induction of labour.MethodAn antenatal survey of women booked for an induction at eight Sydney hospitals was conducted. A bespoke questionnaire was created assessing women’s demographics, indication for induction, pregnancy model of care, initial birth preferences, and their experience of the decision-making process.ResultsOf 189 survey respondents (58% nulliparous), major reported reasons for induction included prolonged pregnancy (38%), diabetes (25%), and suspected fetal growth restriction (8%). Most respondents (72%) had hoped to labour spontaneously. Major findings included 19% of women not feeling like they had a choice about induction of labour, 26% not feeling adequately informed (or uncertain if informed), 17% not being given alternatives, and 30% not receiving any written information on induction of labour. Qualitative responses highlight a desire of women to be more actively involved in decision-making.ConclusionA substantial minority of women did not feel adequately informed or prepared, and indicated they were not given alternatives to induction. Suggested improvements include for face-to-face discussions to be supplemented with written information, and for shared decision-making interventions, such as the introduction of decision aids and training, to be implemented and evaluated.     

The role of support person for Ngaanyatjarra women during pregnancy and birth

BackgroundThis study took place in a remote community on the Ngaanyatjarra Lands, Western Australia. Ngaanyatjarra women's cultural practices have been subject to erosion during the past 70 years. Women are now expected to birth hundreds of kilometres from home and, due to financial barriers, without family support. Older women lament their lack of input into, and control of, contemporary birthing services.Research questionIn order to provide culturally appropriate maternity services we asked: What issues would the Ngaanyatjarra women of the community like to see resolved in the area of antenatal and birthing services?Participants and methodsEligible participants were any Ngaanyatjarra women of the study community who had birthed at least once. We utilised a participatory research methodology. 36 women were interviewed.FindingsThis paper discusses one finding related to support for child-bearing women. The role is important in many ways. Ngaanyatjarra women did not traditionally have their support persons with them during labour and birth, nor do they necessarily expect them to be present in current times. Most women do, however, wish to have a support person with them during antenatal checkups and when they travel to town to await birth.ConclusionAboriginal women from remote communities should be able to have a support person with them when they access regional birthing services, but the nature of this role must not be assumed. A culturally appropriate service has input from the community, provides options and respects choices.     

Does introducing a dedicated early labour area improve birth outcomes? A pre-post intervention study

ProblemWomen increasingly present to hospital in early labour, but admission before active labour contributes to overuse of interventions, poorer clinical and psychological outcomes, and higher healthcare costs.BackgroundInnovative models of early labour care have so far not improved birth outcomes.AimTo examine if reconfiguring the early labour service in a large Australian maternity service improved (1) the birth outcomes of women who presented in early labour and (2) alleviated bed blockages by decreasing length of stay in the Pregnancy Assessment and Observation Unit.MethodsPre-post intervention design, using routinely collected clinical data before and after the implementation of the reconfigured early labour service.FindingsThere were 527 women in pre-intervention cohort and 747 in the post-intervention cohort. The two groups were similar in age, body mass index, marital status, education level and gestation at birth. Post intervention, epidural use did not change significantly, but rates of amniotomy (35.7% vs. 49.9%, p = <0.001), meconium-stained liquor (20.1% vs 26.1%, p = 0.04), and neonatal nursery admission (2.7% vs. 5.8% p = 0.01) increased. The proportion of women staying in the Assessment unit more than two hours decreased, but not significantly.ConclusionChanging the location and model of early labour care did not influence epidural use, nor improve women’s birth outcomes. For women in early labour, admission to any location within the hospital may be as problematic as admission to birth suite specifically.     

Experiences and outcomes on the use of telemetry to monitor the fetal heart during labour: findings from a mixed methods study

BackgroundWireless continuous electronic fetal monitoring (CEFM) using telemetry offers potential for increased mobility during labour. United Kingdom national recommendations are that telemetry should be offered to all women having CEFM during labour. There is limited contemporary evidence on experiences of telemetry use or impacts it may have.AimTo gather in-depth knowledge about the experiences of women and midwives using telemetry, and to assess any impact that its use may have on clinical outcomes, mobility in labour, control or satisfaction.MethodsA convergent parallel mixed-methods study was employed. Grounded theory was adopted for interviews and analysis of 13 midwives, 10 women and 2 partners. Satisfaction, positions during labour and clinical outcome data was analysed from a cohort comparing telemetry (n = 64) with wired CEFM (n = 64). Qualitative and quantitative data were synthesised to give deeper understanding.FindingsWomen using telemetry were more mobile and adopted more upright positions during labour. The core category A Sense of Normality encompassed themes of ‘Being Free, Being in Control’, ‘Enabling and Facilitating’ and ‘Maternity Unit Culture’. Greater mobility resulted in increased feelings of internal and external control and increased perceptions of autonomy, normality and dignity. There was no difference in control or satisfaction between cohort groups.ConclusionsWhen CEFM is used during labour, telemetry provides an opportunity to improve experience and support physiological capability. The use of telemetry during labour contributes to humanising birth for women who have CEFM and its use places them at the centre and in control of their birth experience.     

What are the facilitators,inhibitors, and implications of birth positioning? A review of the literature

BackgroundFrom the historical literature it is apparent that birthing in an upright position was once common practice while today it appears that the majority of women within Western cultures give birth in a semi-recumbent position.AimTo undertake a review of the literature reporting the impact of birth positions on maternal and perinatal wellbeing, and the factors that facilitate or inhibit women adopting various birth positions throughout the first and second stages of labour.MethodsA search strategy was designed to identify the relevant literature, and the following databases were searched: CINAHL, CIAP, the Cochrane Database of Systematic Reviews, Medline, Biomed Central, OVID and Google Scholar. The search was limited to the last 15 years as current literature was sought. Over 40 papers were identified as relevant and included in this literature review.ResultsThe literature reports both the physical and psychological benefits for women when they are able to adopt physiological positions in labour, and birth in an upright position of their choice. Women who utilise upright positions during labour, have a shorter duration of the first and second stage of labour, experience less intervention, and report less severe pain and increased satisfaction with their childbirth experience than women in a semi recumbent or supine/lithotomy position. Increased blood loss during third stage is the only disadvantage identified but this may be due to increased perineal oedema associated with upright positions. There is a lack of research into factors and/or practices within the current health system that facilitate or inhibit women to adopt various positions during labour and birth. Upright birth positioning appears to occur more often within certain models of care, and birth settings, compared to others. The preferences for positions, and the philosophies of health professionals, are also reported to impact upon the position that women adopt during birth.ConclusionUnderstanding the facilitators and inhibitors of physiological birth positioning, the impact of birth settings and how midwives and women perceive physiological birth positions, and how beliefs are translated into practice needs to be researched.