Given the cross section of women giving birth in the UK at present, isolating what woman want from and in labour and birth can be something of a tall order for midwifery and medical staff alike, and is dependent not only on their place of practice, but on the ethos of care surrounding the workplace.
As a community midwife with a varied caseload, in just one week I can encounter requests for an intervention-free birth in a yacht, little or no fetal monitoring in labour at home, to a determined demand for an epidural at the first signs of active labour, or an elective caesarean section following a traumatic first birth. Every one of those women and their partners has a different expectation of what their child’s first moments will be. Ensuring those expectations are satisfied, is where the hard work begins!
Judging by some of the adverse press reporting that surrounds the sensitive subject of labour and birth, we know that we as a community of health carers (including managers and NHS commissioners) don’t always get it right. However, we can be guided by some of the research into what women and their partners seek from their birth experience.
Fundamentally, normal physiological birth remains a desired outcome for many of the world’s women (Young, 2003, Klein 2006, Kitzinger 2006). This is despite the media’s well documented ‘too posh to push’ syndrome where women are reported as demanding an elective caesarean section with no medical indication. According to Dr Maggie Blott, consultant obstetrician at University College Hospital and RCOG spokeswoman on caesareans, these requests account for a small proportion of caesarean births, less than one percent of all those performed in the UK (The Observer, 26TH October 2007).
Anyone who works in a Central Delivery Suite, however, will know that the interpretation of ‘normality’ in birth is the subject of fierce debate amongst midwives and doctors and represents an enormous and varied range; with or without epidural? With or without Syntocinon? Episiotomy? Women may rate a ‘normal’ birth with interventions as highly unsatisfactory, and yet on paper (and therefore in statistical terms), it is rated by the NHS as a successful outcome. Anyone who works in maternity care will also know that how women perceive their experiences is often at odds with how professionals regard the care given.
What we do know is that women’s expectations and desires are affected by what is on offer, and the choices laid out. One Scottish study by Hundley & Ryan (2004) looked at how women from different geographical areas would shape their own maternity care if they were given a variety of options. The study showed that generally, and across all areas, women preferred their care in labour and birth to include:
- a midwife whom they had met during their pregnancy and who would be present throughout labour and delivery;
- all methods of pain relief available;
- intermittent monitoring;
- homely surroundings;
- involvement of medical staff only if required;
- greater involvement/control in decision making.
However, the study also demonstrated that women from areas where there was already a lesser degree of continuity in care did not value the familiarity with a known midwife in labour, as highly as those who had experienced good continuity. The study concluded that the systems of care already available shaped how women wanted their care to be (Hundley & Ryan 2004).
This begs the question, in terms of planning models of care, is it the chicken or the egg? How will women know what they can expect and what they can access? i.e. what they may want, if they don’t already have a comprehensive maternity ‘menu’ in place ? The same argument could be applied to homebirth, where many women either don’t know it is technically available in all areas, or that all women – regardless of professional recommendations on place of birth – are entitled to birth at home ?
Two UK studies have sought to provide a framework for elements in labour and birth that are important to prospective parents.
In 2005, The National Childbirth Trust surveyed more than 600 women who had given birth in a variety of settings in a bid to find out what they want from their birth environment. The majority of women wanted a clean room they were able to stay in during the whole labour, large enough to walk around, and with an adjustable bed and a comfortable chair. In addition, they valued the availability of mats, birth balls, bean bags and low level lighting (NCT 2005).
Aside from the practical environment, however, women listed continuous midwifery care as helping with their labour; those who had received one-to-one care were more likely to say they had received excellent midwifery care (77%), compared with women who did not have continuous support (50%) (NCT 2005). Woman also said they valued suggestions from their carers for coping with labour, such as different positions, focused breathing or being mobile. They found it supportive when midwives praised, encouraged and motivated them throughout their labour (NCT 2005).
These findings reiterate a review of 15 randomised controlled trials, including 13,000 women, which found that continuous support during labour increases women’s reported satisfaction with their care and reduces the need for pain relieving drugs and ventouse of forceps births (Hodnett et al, 2006).
The most recent comprehensive survey of women’s experiences in labour and birth in England was carried out by the Healthcare Commission in 2007, where 26,000 women responded to a detailed questionnaire on care they received. One of the most important elements of labour care for women was shown to be confidence in the staff caring for them; 68% of those questioned said they “definitely” had confidence and trust in the staff assigned, and 27% said they had confidence “to some extent”.
Following on from the findings by the Department of Health (2004), the study found women preferred to be cared for by a midwife whom they had got to know and trust in pregnancy. However, only 22% had previously met the staff who were providing the care in labour.
The same Healthcare Commission report found that during labour and birth, 26% of women said they had been left alone by midwives or doctors, at a time when it worried them, and 30% said they did not feel involved in decisions about their care. (Healthcare Commission 2007).
Clearly, in some areas, we could draw the conclusion that there is a shortfall in the expectation or the needs of women and the delivery of the care. However, it is also worth noting that in the same survey 89% of women rated their overall care in labour as “excellent”, “very good” or “good” and 82% said they were spoken to in a way they could understand (Healthcare Commission 2007).
Despite what surveys tell us, we as health carers know there is no prescription for a perfect birth scenario. While we can adjust staff numbers and practically change the appearance of the birthplace, it is harder to assess and quantify how women feel when they enter into a birth environment.
One qualitative US study of women’s birth experiences found that women entering hospital to give birth for the first time can feel intimidated and may feel a loss of control, which in turn can lead to a loss of dignity (Matthews & Callister 2004). In preparing for the survey, their literature search suggested women wanted to be treated with respect and have control over their decision-making, an element which had an important knock-on effect on the quality of their birth experience and overall satisfaction with care.
The survey itself, although small, concluded that nursing staff (in the American model) had a crucial role in preserving dignity through support, encouragement and continuity of care. Some mothers in particular, spoke of the importance of a positive attitude and effective communication in helping to stay in control in labour and birth. (Matthews & Callister 2004).
Back in the UK, the NICE guidelines on Intrapartum Care (NICE 2007) appear to have absorbed the trends in such research, and play heavily on words such as “kindness”, “respect” and dignity” in laying out care. “The views, beliefs and values of the woman, her partner and her family in relation to her care and that of her baby should be sought and respected at all times”, says the introduction on woman and baby-centred care (NICE 2007, guideline 55, p.6)
As a practising midwife, I wholeheartedly applaud the principle, but wonder in reality how much it is actually practised in busy maternity units up and down the country, how much (real) choice is given about induction of labour and the wishes of women, for instance, and ‘informed consent’ for intervention in labour ? I also wonder how many birth plans are read and then simply (dis)regarded as too idealistic and too prescriptive, when they could easily form the base of a plan of care, particularly if the birth scenario changes swiftly from low to high-risk, for instance. As a midwife, I feel a birth plan is still a valuable document in communicating an ethos of care that’s desired, even if the details necessarily change.
Anecdotally, I spend a great deal of my professional time both in formulating birth plans with parents – and at the other end of the scale – in accessing birth notes and acting as interpreter between parents and their birth experience, when a great deal of it has been understandably hazy at the time. From my point of view, the main issue for parents is a lack of explanation from staff at the time, usually of proposed interventions and the reasons behind them. As someone who has trained and then worked on a busy delivery suite, I can also see how that perception is formed, when women are labouring and partners are worried; explanations can be given but may not be absorbed when contractions are intense and the focus is on a safe arrival for the baby.
What is clear from research, though, is how the language of delivery suite can be misunderstood and may contribute to how women interpret their care.
In research on nursing/patient interaction, Hewison (199%) found verbal communication was a power tool in ensuring that patients were aware of their submissive role and compliance in hospital routines and procedures. In relation to childbirth, Nichols and Humernick (2000) discuss the need for positive expression surrounding birth based on neurolinguistic science, which suggests that language affects the brain and the nervous system (and therefore, we could assume, the body’s ability to labour).
In one experiment on language, Miles (1984) compared the differing perspectives on childbirth between parents and obstetricians. In a discussion on an alternative birth centre, both groups comments were recorded; obstetricians had a tendency to use words associated with control, such as “death, risk, protection, proof, management” etc. while parents chose care-orientated, subjective words – “family, love, bonding, feelings, anxiety” etc. – and yet both were discussing the same subject (Miles 1984).
Again, the NICE guidelines have accepted the importance of information-giving as a way forward in improving maternity care. Under the heading ‘key priorities for implementation’, NICE lists ‘communication’ as a top priority, and is fairly prescriptive in it suggestions for delivery: “….healthcare professionals and other caregivers should establish a rapport with the labouring women, asking her about her wants and expectations for labour, being aware of the importance of tone and demeanour, and of the actual words they use” (NICE 2007, clinical guideline 55, p.7).
Personally, I note (and applaud) the frequent use of ‘birth’ in the NICE literature, as opposed to ‘delivery’. However, I also note that most midwives and doctors I come into contact with (in both high and low risk care) still use the word ‘delivery’, even if they are speaking of a baby’s arrival in a positive, glowing light. It’s still a description that sticks in my throat, since I firmly believe in the old saying: “Parcels are delivered, but babies are born”. It’s a small ask, but if we begin to speak of having babies as a ‘birth’, then maybe, just maybe, some of our other language will follow suit?
Among such a plethora of new guidelines, protocols and endless new initiatives – all accompanied for ever increasing paperwork – it is no wonder that as healthcare professionals we don’t always get it right. The literature would suggest that in the UK at least, we are meeting the requests and responding to women’s needs some but not all of the time. The media, however, would have us (and possibly the wider population) believe that some women in busy maternity units are entering a hospital of third world dimensions. The reality is probably somewhere in the middle.
The NICE guidelines have gone some way to providing a framework for equity of care across geographical boundaries, with guidelines that could be absorbed across trusts and maternity units. How much is actually adopted, either as a package or a clinical pick’n’mix remains to be seen. It is, of course, much harder to impose an ethos of care than simply paper guidelines; ethos only grows with time, personal commitment and passion.
What is clear from surveys and from parental feedback, is that women want to be treated with respect, to understand what is happening to them in their labour, and on a more prescriptive level, they want continuous support from a carer. This, of course, has implications on time and on staffing – something which is in short supply in many maternity units in the UK at present. The midwifery world is constantly evaluating the way it delivers care, everything from team midwifery, to caseload, or the more common system of shared care.
It’s a tall order; the majority of maternity units need more staff, but it can work if health carers are prepared to be flexible, and rewarded for their flexibility. We can deliver the care, and the babies – of course – can be ‘born’!
Mandy Robotham is a community midwife in Stroud, Gloucestershire.
- Department of Health (2004). National Service Framework for Children, Young People and Maternity Services. DOH.
- Healthcare Commission, November 2007. Women’s experiences of maternity care in the NHS in England. Healthcare Commission.
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- National Childbirth Trust 2005 (Newburn M, Singh D) Are woman getting the birth environment they need ? Report of a national survey of women’s experiences. NCT London.
- NICE 2007. Clinical Guideline 55 – Intrapartum Care. National Institute for Clinical Excellence.
- Nichols F, Humenick S. Childbirth education, practice, research and theory. 2nd edition. Philadelphia,: WB Saunders 2000.
- The Observer, 26th October 2008. “Fear of pain” causes big rise in Caesareans. News, p.8, author: Denis Campbell.
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