W2: They don’t have respect for the female body and its ability to give birth. There was no humanity, only medicine. The environment among the staff was poor, they didn’t appear to read the medical record, and everyone had to come up with their own solutions. They don’t listen to one’s objections and it was so poorly staffed that the father basically had to help with everything, yet there was no room for him. I didn’t feel safe and didn’t get the help I needed.
Discussion
Main findings
The analysis resulted in a rich and nuanced body of information about what women who have given birth in Norway emphasise as important aspects of care during childbirth. The findings demonstrate that socio-cultural and psychological aspects of care are significant for women in childbirth, alongside physical and clinical factors. Some of the findings reflect earlier research, including the desire for compassionate and respectful care, continuity of care and safety. Women who gave birth in Norway emphasise that respectful maternity care encompasses more than absence of disrespectful care or mistreatment during childbirth,18-21 they also value empathetic and sensitive clinical staff. 2,22 In our study, continuity of care was highlighted as good care and called for when it was missing. This reflects the desire for and satisfaction with continuity of care, which is a common research finding.22,23 In our study, the concept of continuity encompasses consistency of information between clinical staff and wards, and continuity of the experience of pregnancy, labour and birth, and even continuity between pregnancies.
The Family Focus theme illustrates new and unique nuances in women’s views on the importance of family-oriented care; it is perceived as pivotal that the partner is involved, included and cared for both emotionally and through the provision of good facilities, which is also found in studies on fathers’ experiences and expectations of childbirth.24-29 Furthermore, our results suggest that the value of looking after birth companions is a way of looking after the woman herself. If she does not have to worry about the wellbeing of her partner, she can commit to the labour process.
The theme ‘sense of security’ goes beyond ‘being safe’. The findings demonstrate that the notion of safety and security varies, and that the perception of the concept is individual and complex, which is also found in other studies.28 This is reflected in the contrasting rationale for feeling safe; some felt safe giving birth in a high-tech hospital ward with monitoring and emergency preparedness, while others felt safe giving birth at home with a midwife they knew well in familiar surroundings.
Strengths and limitations
To our knowledge, this is the largest study of women’s childbirth experiences ever conducted in Norway. In 2018, 93% of Norwegian women between 18 and 44 had a profile on Facebook, 98% of these used Facebook weekly.30 Social media was thus a feasible platform for recruiting participants. The study sample characteristics were very similar to those of the eligible population.
We had limited opportunity to match more demographic characteristics of the study population to the national data such as education, migration and socio-economic inequity. Survey studies have some methodological limitations such as response and recall bias. Further studies could target specific and more marginalised groups.
Interpretation
Our interpretation of the findings identify new nuances in the care of women during childbirth; the need for an increased family focus in care, sensitivity to the women’s individuality regarding the notion of safety and security, to understand childbirth as a continuous experience in the context of women’s lives and to maintain and promote a coherent experience.
The women expressed an explicit wish for family-oriented care. This raises the suggestion that women might not be able to enter the ‘flow state’, neuropsychologically, if they are concerned about the wellbeing of others in attendance who they care about.31 It also underlines that women view the process of giving birth as a transition towards ’becoming a family’ or ’expanding the family’. Shifting roles from woman to mother and man to father or from couple to parents. In light of the theory of ‘rite de passage’ and liminality, transition refers to a change of status, and ambiguity and vulnerability in connection with this change.32
The women’s notion of safety and security revealed a complexity that can depend on multiple internal and external factors.28One interpretation is to assume that if the woman’s ideas and beliefs are shared, or at least respected, by the staff and the organisation where the birth takes place, the associated notion of safety and security can reinforce the woman’s sense of security. The sense of freedom that women reported when they felt totally secure was, as for family support, a sense of relief that they could trust the staff to deal with extraneous matters and threats. This meant that they were free to disconnect external vigilance, enabling them to internalise their focus on giving birth.31
The women’s experience of continuity comprised a sense that each stage of the process, at each level of their experience, was interconnected and this was reinforced if there was no sense of discontinuity even when different staff were involved. The findings coincide with those of others who have suggested that women’s experiences during labour and birth does not correspond to physically defined stages, but go beyond this to a life-course concept of continuity, which needs to be recognised by staff when they encounter women in labour.33-36
The overarching theme brings these findings of seamlessness together, by incorporating the notion ‘Coherence’.11 In this sense, a coherent labour and birth experience encompasses all the themes, assuming that childbirth can be experienced as meaningful, manageable and comprehensible. A strong sense of coherence (SOC) is associated with positive emotions both regarding birth and the baby, while a weak SOC is expressed through negative emotions and worries relating to labour and birth.37 It is claimed that women need to organise their childbearing experience into a coherent narrative.38 However, it may be challenging for women to create and maintain a coherent narrative, as the transition to motherhood is both private and public, social and biological and influenced by their own or others’ expectations.38 Our findings suggest that maternity care that reflects all four themes could help women to create coherent experiential narratives optimising their wellbeing, and that of their baby, partner and family, into the future. Beyond this, it is plausible that women who feel a sense of coherence in childbirth are more able to activate parts of the neocortex required for the neurohormonal processes that facilitate optimal birth physiology and post-birth adjustment.31
Conclusion
Socio-cultural and psychological aspects of care are significant for women in childbirth, alongside physical and clinical factors. Compassionate and respectful care encompasses empathetic and sensitive staff, and a sense of the care being genuinely intended. Caring for the woman implies caring for her partner and having a baby is about ‘becoming a family or expanding the family’. How maternity services meet both parents’ needs are therefore crucial. Women’s notion of safety and security is individual and complex. Childbirth is a continuous experience in the context of women’s lives and continuity and consistency are important for women to maintain and promote a coherent experience, which refers to the woman’s experience of childbearing as a whole.

Disclosure of interest

The authors report no conflict of interest.

Contribution of authorship

The conception and design of the work: CV, ABVN, EB, SD, TSE. Acquisition of data: CV, ABVN, EB, SD, TSE. Analysis and interpretation of data: CV, ABVN, EB, SD, TSE. Drafting the work and revising it critically for important intellectual content: CV, ABVN, EB, SD, TSE.

Details of ethics approval

Ethical approval was granted by the Ethics Committee of the University of Central Lancashire, UK (Ethics Committee BuSH 222). The study was approved by the Norwegian Data Inspectorate (ref: 60547/3/HJTIRH), no further ethical clearance was necessary (ref: 2017/1582).

Funding

CV was funded by a PhD scholarship from Oslo Metropolitan University.

Acknowledgement

This study was derived from the Babies Born Better project, developed as a part of two EU COST Actions supported by the Cost (European Cooperation in Science and Technology Programme as a part of European Horizon 2020): 1) COST-Action IS0907 “Childbirth Cultures, Concerns, and Consequences: Creating a dynamic European Union framework for optimal maternity care”; and 2) COST-Action IS1405: Building Intrapartum Research Through Health—an interdisciplinary whole system approach to understanding and contextualizing physiological labour and birth (BIRTH).