Key dimensions of women's and their partners' experiences of childbirth: A systematic review of reviews of qualitative studies

BACKGROUND

The World Health Organization 2018 intrapartum guideline for a positive birth experience emphasized the importance of maternal emotional and psychological well-being during pregnancy and the need for safe childbirth. Today, in many countries birth is safe, yet many women report negative and traumatic birth experiences, with adverse effects on their and their families' well-being. Many reviews have attempted to understand the complexity of women's and their partners' birth experience; however, it remains unclear what the key dimensions of the birth experience are.

OBJECTIVE

To synthesize the information from reviews of qualitative studies on the experience of childbirth in order to identify key dimensions of women's and their partners' childbirth experience.

METHODS

Systematic database searches yielded 40 reviews, focusing either on general samples or on specific modes of birth or populations, altogether covering primary studies from over 35,000 women (and >1000 partners) in 81 countries. We appraised the reviews' quality, extracted data and analysed it using thematic analysis.

FINDINGS

Four key dimensions of women's and partners' birth experience (covering ten subthemes), were identified: 1) Perceptions, including attitudes and beliefs; 2) Physical aspects, including birth environment and pain; 3) Emotional challenges; and 4) Relationships, with birth companions and interactions with healthcare professionals. In contrast with the comprehensive picture that arises from our synthesis, most reviews attended to only one or two of these dimensions.

CONCLUSIONS

The identified key dimensions bring to light the complexity and multidimensionality of the birth experience. Within each dimension, pathways leading towards negative and traumatic birth experiences as well as pathways leading to positive experiences become tangible. Identifying key dimensions of the birth experience may help inform education and research in the field of birth experiences and gives guidance to practitioners and policy makers on how to promote positive birth experiences for women and their partners.

Traumatic birth and childbirth-related post-traumatic stress disorder: International expert consensus recommendations for practice, policy, and research

BACKGROUND

Research suggests 1 in 3 births are experienced as psychologically traumatic and about 4% of women and 1% of their partners develop post-traumatic stress disorder (PTSD) as a result.

AIM

To provide expert consensus recommendations for practice, policy, and research and theory.

METHOD

Two consultations (n = 65 and n = 43) with an international group of expert researchers and clinicians from 33 countries involved in COST Action CA18211; three meetings with CA18211 group leaders and stakeholders; followed by review and feedback from people with lived experience and CA18211 members (n = 238).

FINDINGS

Recommendations for practice include that care for women and birth partners must be given in ways that minimise negative birth experiences. This includes respecting women's rights before, during, and after childbirth; and preventing maltreatment and obstetric violence. Principles of trauma-informed care need to be integrated across maternity settings. Recommendations for policy include that national and international guidelines are needed to increase awareness of perinatal mental health problems, including traumatic birth and childbirth-related PTSD, and outline evidence-based, practical strategies for detection, prevention, and treatment. Recommendations for research and theory include that birth needs to be understood through a neuro-biopsychosocial framework. Longitudinal studies with representative and global samples are warranted; and research on prevention, intervention and cost to society is essential.

CONCLUSION

Implementation of these recommendations could potentially reduce traumatic births and childbirth-related PTSD worldwide and improve outcomes for women and families. Recommendations should ideally be incorporated into a comprehensive, holistic approach to mental health support for all involved in the childbirth process.

Developing a woman-centered, inclusive definition of traumatic childbirth experiences: A discussion paper

INTRODUCTION

Many women experience giving birth as traumatic. Although women's subjective experiences of trauma are considered the most important, currently there is no clear inclusive definition of a traumatic birth to help guide practice, education, and research.

AIM

To formulate a woman-centered, inclusive definition of a traumatic childbirth experience.

METHODS

After a rapid literature review, a five-step process was undertaken. First, a draft definition was created based on interdisciplinary experts' views. The definition was then discussed and reformulated with input from over 60 multidisciplinary clinicians and researchers during a perinatal mental health and birth trauma research meeting in Europe. A revised definition was then shared with consumer groups in eight countries to confirm its face validity and adjusted based on their feedback.

RESULTS

The stepwise process confirmed that a woman-centered and inclusive definition was important. The final definition was: "A traumatic childbirth experience refers to a woman's experience of interactions and/or events directly related to childbirth that caused overwhelming distressing emotions and reactions; leading to short and/ or long-term negative impacts on a woman's health and wellbeing."

CONCLUSIONS

This definition of a traumatic childbirth experience was developed through consultations with experts and consumer groups. The definition acknowledges that low-quality provider interactions and obstetric violence can traumatize individuals during childbirth. The women-centered and inclusive focus could help women to identify and validate their experiences of traumatic birth, offering benefits for practice, education, and research, as well as for policymaking and activism in the fields of perinatal mental health and respectful maternity care.

Developing a woman-centered, inclusive definition of positive childbirth experiences: A discussion paper

INTRODUCTION

A positive childbirth experience promotes women's health, both during and beyond the perinatal period. Understanding what constitutes a positive childbirth experience is thus critical to providing high-quality maternity care. Currently, there is no clear, inclusive, woman-centered definition of a positive childbirth experience to guide practice, education, and research.

AIM

To formulate an inclusive woman-centered definition of a positive childbirth experience.

METHODS

A six-step process was undertaken: (a) Key concepts associated with a positive childbirth were derived from a rapid literature review; (b) The key concepts were used by interdisciplinary experts in the author group to create a draft definition; (c) The draft definition was presented to clinicians and researchers during a European research meeting on perinatal mental health; (d) The authors integrated the expert feedback to refine the working definition; (e) A revised definition was shared with women from consumer groups in six countries to confirm its face validity; and (f) A final definition was formulated based on the women's feedback (n = 42).

RESULTS

The following definition was formulated: "A positive childbirth experience refers to a woman's experience of interactions and events directly related to childbirth that made her feel supported, in control, safe, and respected; a positive childbirth can make women feel joy, confident, and/or accomplished and may have short and/or long-term positive impacts on a woman's psychosocial well-being."

CONCLUSIONS

This inclusive, woman-centered definition highlights the importance of provider interactions for facilitating a positive childbirth experience. Feeling supported and having a sense of control, safety, and respect are central tenets. This definition could help to identify and validate positive childbirth experience(s), and to inform practice, education, research, advocacy, and policy-making.

Birth as a neuro-psycho-social event: An integrative model of maternal experiences and their relation to neurohormonal events during childbirth

BACKGROUND

Psychological aspects of labor and birth have received little attention within maternity care service planning or clinical practice. The aim of this paper is to propose a model demonstrating how neurohormonal processes, in particular oxytocinergic mechanisms, not only control the physiological aspects of labor and birth, but also contribute to the subjective psychological experiences of birth. In addition, sensory information from the uterus as well as the external environment might influence these neurohormonal processes thereby influencing the progress of labor and the experience of birth.

METHODOLOGY

In this new model of childbirth, we integrated the findings from two previous systematic reviews, one on maternal plasma levels of oxytocin during physiological childbirth and one meta-synthesis of women´s subjective experiences of physiological childbirth.

FINDINGS

The neurobiological processes induced by the release of endogenous oxytocin during birth influence maternal behaviour and feelings in connection with birth in order to facilitate birth. The psychological experiences during birth may promote an optimal transition to motherhood. The spontaneous altered state of consciousness, that some women experience, may well be a hallmark of physiological childbirth in humans. The data also highlights the crucial role of one-to-one support during labor and birth. The physiological importance of social support to reduce labor stress and pain necessitates a reconsideration of many aspects of modern maternity care.

CONCLUSION

By listening to women's experiences and by observing women during childbirth, factors that contribute to an optimized process of labor, such as the mothers' wellbeing and feelings of safety, may be identified. These observations support the integrative role of endogenous oxytocin in coordinating the neuroendocrine, psychological and physiological aspects of labor and birth, including oxytocin mediated. decrease of pain, fear and stress, support the need for midwifery one-to-one support in labour as well as the need for maternity care that optimizes the function of these neuroendocrine processes even when birth interventions are used. Women and their partners would benefit from understanding the crucial role that endogenous oxytocin plays in the psychological and neuroendocrinological process of labor.

Women's psychological experiences of physiological childbirth: a meta-synthesis

OBJECTIVE

To synthesise qualitative studies on women's psychological experiences of physiological childbirth.

DESIGN

Meta-synthesis.

METHODS

Studies exploring women's psychological experiences of physiological birth using qualitative methods were eligible. The research group searched the following databases: MEDLINE, CINAHL, PsycINFO, PsycARTICLES, SocINDEX and Psychology and Behavioural Sciences Collection. We contacted the key authors searched reference lists of the collected articles. Quality assessment was done independently using the Critical Appraisal Skills Programme (CASP) checklist. Studies were synthesised using techniques of meta-ethnography.

RESULTS

Eight studies involving 94 women were included. Three third order interpretations were identified: 'maintaining self-confidence in early labour', 'withdrawing within as labour intensifies' and 'the uniqueness of the birth experience'. Using the first, second and third order interpretations, a line of argument developed that demonstrated 'the empowering journey of giving birth' encompassing the various emotions, thoughts and behaviours that women experience during birth.

CONCLUSION

Giving birth physiologically is an intense and transformative psychological experience that generates a sense of empowerment. The benefits of this process can be maximised through physical, emotional and social support for women, enhancing their belief in their ability to birth and not disturbing physiology unless it is necessary. Healthcare professionals need to take cognisance of the empowering effects of the psychological experience of physiological childbirth. Further research to validate the results from this study is necessary.

PROSPERO REGISTRATION NUMBER

CRD42016037072.

The primacy of the good midwife in midwifery services: an evolving theory of professionalism in midwifery

Theory is the acknowledged foundation to practise methodology, professional identity and growth of formalized knowledge. It has been noted that practice must not only be evidence-based but also theory-based. Hence, midwifery must be theory based because theories serve as a broad framework for practice and may also articulate the goals of a profession and core values. In this paper, an evolving theory on the empowerment of childbearing women is introduced, where the midwife's professionalism is central. The theory is synthesized from nine datasets and scholarly work, and then more than three hundred studies were reviewed for clarification and confirmation. According to the theory, the midwife's professionalism is constructed from five main aspects: The professional midwife cares for the childbearing woman and her family. This caring within the professional domain is seen as the core of midwifery. The professional midwife is professionally competent. This professional competence must always have primacy for the sake of safety of woman and child. The professional midwife has professional wisdom and knows how to apply it. Professional wisdom is a new concept used to denote the interplay of knowledge and experience. The professional midwife has interpersonal competence, is capable of empowering communication and positive partnership with the woman and her family. The professional midwife develops herself both personally and professionally, which is the prerequisite for true professionalism. This evolving theory must be regularly reconstructed in the light of current knowledge within midwifery. It is an attempt to identify and articulate the processes and components of the art and science of midwifery practice in an endeavour of continuing the discipline's development by assisting in the understanding and practice of creating further theoretical discourse, processes and products for midwifery practice. The theory has implications for midwifery education and practice.

Journeying through labour and delivery: perceptions of women who have given birth

OBJECTIVE

The aim of this study was to explore the essential structure of the lived experience of childbearing, as seen from the perspective of women who have given birth.

DESIGN, SETTING, AND PARTICIPANTS

The phenomenological perspective of qualitative research theory guided the methodological approach to the study, in which interactive interviews were conducted with a purposeful sample of fourteen mothers of healthy babies in Akureyri and Reykjavik, the two most inhabited places in Iceland.

FINDINGS

The metaphor of a woman journeying through labour and delivery was chosen to symbolize the lived experience of giving birth to a healthy baby. This encompasses four major categories: influences of circumstances and expectations before the journey's commencement; a sense of self during the journey which encompasses a sense of being in a private world, the sense of control, the need for caring and understanding and the need for a sense of security; the journey through labour and delivery itself; and finally the first sensitive hours of motherhood and the perception of the uniqueness of birth as a life experience at the journey's end. The study has the potential of increasing the knowledge and understanding of giving birth as a life experience, and therefore, has implications for midwives and nurses, as well as for women and their supporters.

KEY CONCLUSIONS

The lived experience of giving birth is a powerful life experience which is coloured by circumstances and expectations of the woman, her sense of self during the journey, the journey itself, as well as the first sensitive hours of motherhood.

IMPLICATIONS FOR PRACTICE

The study has the potential of increasing the knowledge and understanding of giving birth as a life experience, and therefore, has implications for midwives/nurse, as well as for women and their supporters.