Effects of the birthing room environment on vaginal births and client-centred outcomes for women at term planning a vaginal birth: BE-UP, a multicentre randomised controlled trial

Sacred space: a qualitative interpretive meta-synthesis of women's experiences of supportive birthing environments

BACKGROUND

In the United States there are roughly three million births a year, ranging from cesarean to natural births. A major aspect of the birthing process is related to the healing environment, and how that helps or harms healing for the mother and child. Using the theoretical framework, Theory of Supportive Care Settings (TSCS), this study aimed to explore what is necessary to have a safe and sacred healing environment for mothers.

METHOD

This study utilized an updated Qualitative Interpretive Meta-synthesis (QIMS) design called QIMS-DTT [deductive theory testing] to answer the research question, What are mother's experiences of environmental factors contributing to a supportive birthing environment within healthcare settings?

RESULTS

Key terms were run through multiple databases, which resulted in 5,688 articles. After title and abstract screening, 43 were left for full-text, 12 were excluded, leaving 31 to be included in the final QIMS. Five main themes emerged from analysis: 1) Service in the environment, 2) Recognizing oneself within the birthing space, 3) Creating connections with support systems, 4) Being welcomed into the birthing space, and 5) Feeling safe within the birthing environment.

CONCLUSIONS

Providing a warm and welcoming birth space is crucial for people who give birth to have positive experiences. Providing spaces where the person can feel safe and supported allows them to find empowerment in the situation where they have limited control.

Birth outcomes associated with a natural delivery approach in a perinatal center: A comparative retrospective study

OBJECTIVES

At our center, natural home-like delivery settings have been established in or near conventional labor wards, for the care of pregnant women who prefer little or no medical intervention during labor and birth. We compared obstetrical and neonatal outcomes of women in active spontaneous labor, between those who chose to deliver in a natural-delivery setup and those who chose a conventional setting.

METHODS

This retrospective study included low-risk women who delivered at term between March 1, 2020 and December 31, 2022, in a single tertiary university affiliated medical center. Birth outcomes were compared between 124 women who delivered by natural birth (the study group) and 244 who gave birth in a conventional setting (the control group).

RESULTS

No cesarean deliveries were performed in the study group, compared to 18 (7.4%) of the control group, p = 0.004. Intrapartum fever, postpartum hemorrhage, and uterotonic administration were similar between the groups. For the study compared to the control group, breastfeeding was more common (71.3% vs. 12.3%, p < 0.001), analgesia administration within 48 h delivery was lower (4.1% vs. 10.7%, p = 0.033), and maternal and neonatal length of hospitalization were shorter. Of the women initially admitted to the natural-delivery room, 14 (11.5%) were transferred to a conventional-delivery room.

CONCLUSIONS

Birth in a hospital natural-delivery setting was associated with increased likelihood of vaginal birth, increased immediate breastfeeding and breastfeeding at discharge, and lower postpartum pain.

Birth environment interventions and outcomes: A scoping review

BACKGROUND

The physical environments in which women give birth can contribute positively to meeting both physiologic and psychosocial needs during labor. Most studies on the labor and delivery processes have focused on mitigating pain and providing psychological support. Fewer have explored the influence of the physical birth environment. In this study, we performed a scoping review to compile and examine qualitative and quantitative studies related to the characteristics of physical birth environments and their effects on labor outcomes.

METHODS

We searched the PubMed, CINHAL, Cochrane, Web of Science, and MEDLINE databases from inception to May 2022. A total of 13 studies met the criteria for inclusion in our review. Two reviewers screened the titles and full-text articles and extracted data from the included studies. We used summary statistics and narrative summaries to describe the study characteristics, intervention implementation guidelines, intervention selection and tailoring rationale, and intervention effects.

RESULTS

In previous research, several elements of birth environments have been shown to provide physical and psychological support to birthing people and to improve outcomes related to the experience of care and pain management. We identified five main themes in the included studies: (1) "hominess;" (2) whether spaces are comfortable for activity; (3) demedicalization of the birth environment; (4) accommodations for birth partners; and (5) providing women with a sense of control over their birth environment.

CONCLUSIONS

Birth environments should be designed to promote positive birthing experiences, both physiologically and psychologically. Facilities and those who manage them can improve the experiences and outcomes of service users by modifying or designing spaces that are "homey," comfortable for activity, demedicalized, and include natural elements. In addition, policies that allow the birthing person to control her own environment are key to promoting positive outcomes and satisfaction with the birth experience.

Midwives' perceptions of and experiences with normal physiologic birth: A qualitative systematic review

BACKGROUND

Normal physiologic birth has been shown to result in optimal maternal-infant outcomes, but the concept of physiologic birth is continually evolving. Midwives play an important role in advocating for normal physiologic birth; however, their perceptions of what this approach entails have not been systematically appraised.

OBJECTIVE

In this qualitative review, we aimed to examine midwives' perceived meanings of "normal physiologic birth" and to describe their experiences facilitating such births.

METHODS

Five electronic databases were searched, and 26 qualitative papers were included, representing a total of 433 midwives from different backgrounds (i.e., independent, home-based, community-based, and hospital-based). Eligible papers were assessed for quality, and then data were coded and synthesized thematically.

RESULTS

Four highly connected themes were generated: (1) the midwife: fundamental beliefs; (2) the woman: empowerment and advocacy; (3) the environment: ambience and culture; and (4) the team: need for institutional support and recognition. The fundamental beliefs of midwives, such as their perceived role and definition of normal physiologic birth and their self-confidence, influence practice styles and contribute to personal and professional development. Midwives often advocate for a person-centered approach that encouraged women's and other birthing person's autonomy and involvement in shared decision-making. The midwife-client relationship is also central. Most importantly, a conducive birthing environment and an inclusive workplace culture that encourages interprofessional support, collaboration, and recognizes midwifery practices were identified as crucial in providing optimal conditions for the facilitation of physiologic birth.

CONCLUSIONS

This review provides healthcare policymakers and institutions fresh impetus to evaluate and revise as needed current workplace policies to be more inclusive and supportive of midwifery practices and physiologic birth.

Influence of the birthing room design on midwives' job satisfaction - A cross-sectional online survey embedded in the 'Be-Up' study

BACKGROUND

Job satisfaction is an important factor influencing work performance, personal well-being, commitment and retention. The working environment influences job satisfaction. The design of the birthing room could influence the practice of midwives and their satisfaction. This study investigates whether the alternative design of the birthing room implemented in the randomized controlled trial 'Be-Up' (Birth environment-Upright position) has an impact on job satisfaction of midwives.

METHOD

A cross-sectional survey using an online questionnaire with 50 items addressing job satisfaction and birth room design was performed. The sample (n = 312) consists of midwives whose obstetric units participated in the Be-Up study and, as comparison group, midwives working in non-study obstetric units. These two independent groups were compared using t-tests; correlations and impacts were examined.

RESULTS

The results of the T-tests revealed statistically significant higher global job satisfaction and higher satisfaction with team support of midwives in the Be-Up room. However, midwives working in customary birthing rooms were more satisfied with the design of the room. The most important predictors of job satisfaction were team factors and understaffing in both groups.

CONCLUSION

Reasons for diminished satisfaction with the working environment in the Be-Up study may be assumed in uncertainties about emergency management in a new and unfamiliar environment. Furthermore the impact of a single redesigned room within a customary obstetric unit on job satisfaction seems small, as the room is embedded in the ward and hospital environment. More comprehensive concepts on the potential of the work environment influencing midwives' job satisfaction are needed.

Effect of alternatively designed hospital birthing rooms on the rate of vaginal births: Multicentre randomised controlled trial Be-Up

BACKGROUND

There is limited research into the effects of the birth environment on birth outcomes.

AIM

To investigate the effect of a hospital birthing room designed to encourage mobility, self-determination and uptake of upright maternal positions in labour on the rate of vaginal births.

METHODS

The multicentre randomised controlled trial Be-Up, conducted from April 2018 to May 2021 in 22 hospitals in Germany, included 3719 pregnant women with a singleton pregnancy in cephalic position at term. In the intervention birthing room, the bed was removed or covered in a corner of the room and materials were provided to promote upright maternal positions, physical mobility and self-determination. No changes were made in the control birthing room. The primary outcome was probability of vaginal births; secondary outcomes were episiotomy, perineal tears degree 3 and 4, epidural anaesthesia, "critical outcome of newborns at term", and maternal self-determination (LAS).

ANALYSIS

intention-to-treat.

FINDINGS

The rate of vaginal births was 89.1 % (95 % CI 87.5-90.4%; n = 1836) in the intervention group and 88.5 % (95 % CI 87.0-89.9 %; n = 1863) in the control group. The risk difference in the probability of vaginal birth was + 0.54 % (95 % CI - 1.49 % to 2.57 %), the odds ratio was 1.06 (95 % CI 0.86-1.30). Neither the secondary endpoints nor serious adverse events showed significant differences. Regardless of group assignment, there was a significant association between upright maternal body position and maternal self-determination.

CONCLUSION

The increased vaginal birth rates in both comparison groups can be explained by the high motivation of the women and the staff.

The effect on the birth experience of women and partners of giving birth in a "birth environment room": A secondary analysis of a randomised controlled trial

OBJECTIVE

To evaluate women and partners' experience of birth in a "birth environment room" compared to a standard birth room.

DESIGN

A single centre parallel randomised controlled trial. Women and partners were enrolled during a 3-year period (May 2015 to March 2018).

SETTING

The Department of Obstetrics and Gynaecology at Herning Hospital, Denmark.

PARTICIPANTS AND INTERVENTION

A total of 680 Danish speaking nulliparous women, more than 18 years old, with a singleton pregnancy in cephalic presentation, and a spontaneous onset of labour, and their partners were randomly assigned to give birth in a "birth environment room" (n = 340) or in a standard birth room (n = 340) on arrival at the birth unit.

MEASUREMENTS AND FINDINGS

Outcomes were the overall birth experience and overall satisfaction with care, measured on a Likert scale, obtained in the postpartum questionnaire sent to the women 6 weeks after birth and to their partners 1/2 weeks after birth. Other outcomes were "staff support for partner", "undisturbed contact with new-born", "feeling of being listened to", "level of information", "attention to psychological needs", "suggestions for pain-relief", "participation in decision-making", "midwife present when wanted", "support from midwife", "birth wishes were met", "loss of internal control" (only women), "loss of external control", "support from partner" (partners: "being supportive for partner"), "importance of physical environment for birth" and "importance of physical environment for staff´s ability to involve the women" (only women). All outcomes were prespecified. We applied Mann Whitney U test for comparing the two groups. Data were collected from 326 women and 236 partners in the intervention group and from 315 women and 209 partners in the control group. The intention-to-treat analysis revealed no difference in the overall experience of birth for women or partners (p 0.81 and p 0.17, respectively). Partners in the intervention group reported more overall satisfaction with care compared to partners in the control group (p 0.048). In the intervention group, fewer women and partners responded they had not had the opportunity for undisturbed contact with their new-born in the first hours after birth (RR 0.19 (95% CI 0.04-0.87) and OR 0.00 CI (0.00-0.83), respectively). Otherwise, there were no differences between groups. The thematic analysis revealed that many women and partners felt they were not able to benefit from the features in "the birth environment room" in the most intense hours of birth.

KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE

"The birth environment room" did not improve the overall experience of birth for women and partners. Partners in the intervention group were overall more satisfied with care. These findings are of importance in the developing of physical birth environments that support the mental/emotional process of labour.

The barriers to offering non-pharmacological pain management as an initial option for laboring women: A review of the literature

INTRODUCTION

Many women use pharmacological or non-pharmacological pain management (NPPM) during childbirth, however, evidence shows the usage rates of pharmacological pain management are increasing. The shift towards a biomedical approach to birth care opposes the enduring midwifery philosophy of trusting the woman and her body. Identifying midwives’ beliefs and attitudes towards perceived and actual barriers to offering NPPM as an initial option will provide insight into the factors that affect this.

METHODS

This review of the literature sought to understand midwives’ beliefs and attitudes towards the barriers to offering NPPM as an initial option for laboring women. Peer-reviewed journals were searched for primary research that met the inclusion criteria and explored midwives’ beliefs and attitudes towards the barriers to offering NPPM as an initial option for laboring women. Included studies were evaluated for quality according to the Critical Appraisal Skills Programme (CASP) checklists.

RESULTS

Thirteen qualitative studies met the inclusion criteria and four main themes of barriers to midwives offering NPPM emerged: health system-related, health facility-related, health practitioner-related, and health consumer-related barriers.

CONCLUSIONS

The review of the literature highlighted there are barriers that prevent or delay the initial utilization of non-pharmacological methods of pain management in labor by midwives. These findings can be used as a platform to inform further research into this topic.

Room4Birth - The effect of giving birth in a hospital birthing room designed with person-centred considerations: A Swedish randomised controlled trial

OBJECTIVE

To evaluate if a birthing room designed with person-centred considerations improves labour and birth outcomes for nulliparous women when compared to regular birthing rooms.

METHODS

A randomised controlled trial was conducted at a Swedish labour ward between January 2019 and October 2020. Nulliparous women in spontaneous labour were randomised either to a birthing room designed with person-centred considerations (New room) or a Regular room. The primary outcome was a composite of four variables: vaginal non-instrumental birth; no oxytocin augmentation; postpartum blood loss < 1000 ml; and a positive childbirth experience. To detect a difference of 8% between the groups, 1274 study participants were needed, but the trial was terminated early due to consequences of the Covid-19 pandemic.

RESULTS

A total of 406 women were randomised; 204 to the New room and 202 to the Regular room. There was no significant difference in the primary outcome between the groups (42.2% versus 35.1%; odds ratio: 1.35, 95% Confidence Interval 0.90-2.01; p = 0.18). Participants in the New room used epidural analgesia to a lower extent (54.4% versus 65.3%, relative risk: 0.83, 95% Confidence Interval 0.71-0.98; p = 0.03) and reported to a higher degree that the room contributed to a sense of safety, control, and integrity (p=<0.001).

CONCLUSIONS

The hypothesis that the New room would improve the primary outcome could not be verified. Considering the early discontinuation of the study, results should be interpreted with caution. Nevertheless, analyses of our secondary outcomes emphasise the experiential value of the built birth environment in improving care for labouring women.

Artificial intelligence and the future of midwifery: What do midwives think about artificial intelligence? A qualitative study

The evidence on how AI will make a revolution is insufficient. Our aim was to investigate opinions of midwives on the future of AI and midwifery. Semi-structured interviews were done with 18 midwives in Turkey. Themes were identified: expectations included the advantages and conditional acceptance of robotic technology, prejudices reflected perceived shortcomings, lack of human competencies, and trust issues. Concerns included midwifery care and concerns about her future. Midwives were overwhelmingly skeptical about the replacement of human capabilities by AI and found the technology's potential limited.

Methodological challenges and solution strategies during implementation of a midwife-led multicenter randomized controlled trial (RCT) in maternity hospitals

Background

Randomized controlled trials (RCTs), especially multicentric, with complex interventions are methodically challenging. Careful planning under everyday conditions in compliance with the relevant international quality standard (Good Clinical Practice [GCP] guideline) is crucial. Specific challenges exist for RCTs conducted in delivery rooms due to various factors that cannot be planned beforehand. Few published RCTs report challenges and problems in implementing complex interventions in maternity wards. In Germany as well as in other countries, midwives and obstetricians have frequently little experience as investigators in clinical trials.

Methods

The aim is to describe the key methodological and organizational challenges in conducting a multicenter study in maternity wards and the solution strategies applied to them. In particular, project-related and process-oriented challenges for hospital staff are considered. The exemplarily presented randomized controlled trial “BE-UP” investigates the effectiveness of an alternative design of a birthing room on the rate of vaginal births and women-specific outcomes.

Results

The results are presented in five sectors:

1) Selection of and support for cooperating hospitals: they are to be selected according to predefined criteria, and strategies to offer continuous support in trial implementation must be mapped out.

2) Establishing a process of requesting informed consent: a quality-assured process to inform pregnant women early on must be feasible and effective.

3) Individual digital real-time randomization: In addition to instructing maternity teams, appropriate measures for technical failure must be provided.

4) The standardized birthing room: The complex intervention is to be implemented according to the study protocol yet adapted to the prevailing conditions in the delivery rooms.

5) GCP-compliant documentation: midwives and obstetricians will be instructed in high-quality data collection, supported by external monitoring throughout the trial.

Conclusion

Since not all potential challenges can be anticipated in the planning of a trial, study teams need to be flexible and react promptly to any problems that threaten recruitment or the implementation of the complex intervention. Thought should be given to the perspectives of midwives and obstetricians as recruiters and how clinic-intern processes could be adapted to correspond with the trial’s requirements.

Trial registration

The BE-UP study was registered on 07/03/ 2018 in the German Register for Clinical Trials under Reference No. DRKS00012854 and can also be found on the International Clinical Trials Registry Platform (ICTRP) (see https://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS0001285).

Room4Birth - the effect of an adaptable birthing room on labour and birth outcomes for nulliparous women at term with spontaneous labour start: study protocol for a randomised controlled superiority trial in Sweden

Background

An important prerequisite for optimal healthcare is a secure, safe and comfortable environment. There is little research on how the physical design of birthing rooms affects labour, birth, childbirth experiences and birthing costs. This protocol outlines the design of a randomised controlled superiority trial (RCT) measuring and comparing effects and experiences of two types of birthing rooms, conducted in one labour ward in Sweden.

Methods/design

Following ethics approval, a study design was developed and tested for feasibility in a pilot study, which led to some important improvements for conducting the study. The main RCT started January 2019 and includes nulliparous women presenting to the labour ward in active, spontaneous labour and who understand either Swedish, Arabic, Somali or English. Those who consent are randomised on a 1:1 ratio to receive care either in a regular room (control group) or in a newly built birthing room designed with a person-centred approach and physical aspects (such as light, silencer, media installation offering programmed nature scenes with sound, bathtub, birth support tools) that are changeable according to a woman’s wishes (intervention group). The primary efficacy endpoint is a composite score of four outcomes: no use of oxytocin for augmentation of labour; spontaneous vaginal births (i.e. no vaginal instrumental birth or caesarean section); normal postpartum blood loss (i.e. bleeding < 1000 ml); and a positive overall childbirth experience (7–10 on a scale of 1–10). To detect a difference in the composite score of 8% between the groups we need 1274 study participants (power of 80% with significance level 0.05). Secondary outcomes include: the four variables in the primary outcome; other physical outcomes of labour and birth; women’s self-reported experiences (the birthing room, childbirth, fear of childbirth, health-related quality of life); and measurement of costs in relation to the hospital stay for mother and neonate. Additionally, an ethnographic study with participant observations will be conducted in both types of birthing rooms.

Discussion

The findings aim to guide the design of birthing rooms that contribute to optimal quality of hospital-based maternity care.

Trial registration

ClinicalTrials.gov NCT03948815. Registered 13 May 2019—retrospectively registered.