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).