Background: Physical presence during labour offer women opportunity of having positive childbirth experiences as well as childbirth outcomes. The study aimed to determine what support provided by midwives during intrapartum care at a public hospital in Limpopo Province. The study was conducted at a tertiary hospital in Limpopo Province. Methods: A participant observation approach was used to achieve the objectives of the study. The population comprised of all women who were admitted with labour and for delivery and midwives who were providing midwifery care in the obstetric unit of a tertiary public hospital in Limpopo Province. Non-probability, purposive and convenience sampling were used to sample 24 women and 12 midwives. Data were collected through participant observations which included unstructured conversations with the use of observational guide, field notes of all events and conversations that occurred when women interact with midwives were recorded verbatim and a Visual Analog Scale to complement the observations. Data were analysed qualitatively but were presented in the tables and bar graphs. Results: Five themes emerged as support provided by midwives during labour, namely; communication between women and midwives, informational support, emotional support activities, interpretation of the experienced labour pain and supportive care activities during labour. Conclusion: The communication between woman and midwife was occurring as part of midwifery care and very limited for empowering. The information sharing focused on the assistive actions rather than on the activities that would promote mothers’ participation. The emotional support activities indicated lack of respect and disregard cultural preferences and this contributed to inability to exercise choices in decision-making. The study recommended the implementation of Batho Pele principles in order to provide woman-centred care during labour. Keywords: Support offered, Labour pains, Communication between women and midwives, Informational support, Emotional support, Physical comforting measures Correspondence: firstname.lastname@example.org Department of Advanced Nursing, University of Venda, Private Bag X5050, Thohoyandou 0950, South Africa © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Maputle BMC Pregnancy and Childbirth (2018) 18:210 Page 2 of 11 Background labour was affected by multiple physiological and psy- The Batho-Pele Principles in the White Paper intro- chological factors and its intensity varied greatly. duced a customer-focused approach with the aim of In studies “Experiences of mothers of care provided by transforming systems, procedures, attitudes and behav- midwives during childbirth by Maputle and Nolte  iour within the childbirth units and re-orient midwives and Experiences of midwives of providing care to women in the customers’ favour, an approach which put people during childbirth” by Maputle and Hiss  it was noted first . In this study, the observations were focused on that the labour ward of a tertiary hospital was experien- consultation, standard, courtesy and information. These cing shortage of staff and open plan labour ward with no would be evident when women were treated with cour- privacy and this had negative impact on the allowing the tesy and consideration; it was observed whether mothers male partner to support to women during labour. There were allowed to practice their preferences during child- was shortage of midwives wherein, one midwife would birth (courtesy). The practice in public hospitals, care for more than one woman at the same time. The re- mothers were provided with full and accurate informa- marks cited by mother transcripts’ were: “I couldn’t com- tion regarding childbirth process and midwifery and municate freely with the midwife because she was very intrapartum care which they were entitled to receive (in- busy, but she examined me when I reported/ requested formation). Hence, the researcher conducted the study help. The midwife was busy with other mothers; she was to determine the support provided by midwives to not in my cubicle throughout the childbirth”. This was women during labour at a public hospital in Limpopo supported by the study of Schafheutle et al. ., who Province. Support provision during labour was viewed to indicated that inadequate nursing staff in a shift may be having impact on the childbirth experience as well as contribute to lack of time in providing adequate care on childbirth outcomes . Midwives are there to pro- and this is cited as barrier to effective pain management, vide support to women to offer them strength of facing by interfering with applying non-pharmacological pain challenge of giving birth without losing control [3, 4]. relief methods. Provision of support during labour is important and is In the same study by Maputle and Nolte , authors continuous, so as reduce the risk of medical interven- found that one participant preferred the male partner to tions, like emergency caesarean section or regional anal- be available during childbirth; however, her wish was not gesia maybe less prevalent and labour maybe shorter . honoured because of the physical structure of the ward. The labour supporter could play a major role in increas- Tournaire and Theau-Yonneau  pointed out that the ing women’s chances to have a positive initial breastfeed- availability of doula to provide support was considered ing experience. Rosen  describes support as an an important part of natural pain relief methods. interactive process which may be affected by persons’ Leeman et al.,  advocated for the effective use of age, experience, and personality as well as by the envir- conventional approaches to emphasize the interaction onment . Whereas Simkin  views labour support as between mind, body and environment . Lack of continuous presence, emotional support that includes social and emotional support from partner/ doula or encouragement, guidance, and reassurance; physical excessive medical intervention to women during labour comforting which was assistance in carrying out coping is factors that may be related to increased intensity of techniques, use of touch, massage, positioning, and pain . Labour support could be perceived as the movement) . Simkin further indicate that labour sup- presence of an empathic person who offers information, port includes provision of information and guidance to comforting measures and other forms of tangible assist- the woman and her partner; and to further assist the ance to enable a woman cope with the stress of labour woman to express her needs and wishes; and provision and birth. At this public hospital, women were always of advice, anticipatory guidance, and explanations of pro- alone during labour. In South Africa, the provision of cedures . Labour support was viewed as an affordable midwifery care during labour should be aligned to intervention that responds to the basic emotional and Batho-Pele Principles, namely; consultation, service physical needs of a woman during a painful and vulnerable standard, courtesy, access, information, openness and moment of her reproductive carrier – child birth. transparency, redress and value for money . It was The pain during labour is a physiological phenomenon against this background that the study was conducted. . Ralph et al.  further pointed that, sources of pain during the first stage was associated with reduced blood Methods supply to the uterine muscles during contractions. In the Study design second stage, the source of pain was associated with the A qualitative participatory research approach was used stretching of vaginal wall and perineum and compres- to determine the support provided by midwives to sion of pelvic structures during the passage of descend- women during labour at a public hospital in Limpopo ing head. The pain that women experienced during Province. Maputle BMC Pregnancy and Childbirth (2018) 18:210 Page 3 of 11 Study setting with women and midwives throughout labour, because The study was conducted in the labour ward of a public these conversations were spontaneous and emerged out hospital in Limpopo province, South Africa. The hospital of natural social interaction and contributed to the depth is a 509 bed hospital, out of these beds only 45 were and richness of information that otherwise would have allocated to labouring women. The total number of nor- been difficult to capture through more structured inter- mal deliveries would be ±10 per day. The total number views. Field notes of events were recorded in a notebook of midwives who were allocated in the units during the and conversations that occurred when women interact day was twenty (but on duty there would be eight mid- with midwives were recorded verbatim by the use of a wives, because some would be on leave or off duty). voice recorder. To complement the informal conversa- tions, Visual Analog Scale (VAS) which is an instrument Population and sample and a simple scale was completed by the women and Population comprised of all women, admitted in labour midwives independently during the following dilatations to deliver their babies and the midwives who were pro- of the cervix 0–3, 4–7 and > 8 cm. Recording of field viding midwifery care and who consented to participate notes form a core of record . It entailed both the in the study. Non-probability, convenience and purpos- empirical observations and their interpretation. ive sampling in De Vos et al.,  were used. Only women who were found to be in labour during the day Data analysis of data collection were included in the study. The selec- Biographical data of both women and midwives and the tion of midwife was guided by whether the midwife who data obtained through the unstructured observation is on duty had been already observed when providing guide, the VAS were analysed through frequency distri- care. The inclusion criteria for women were: full term bution and the data were presented as percentages in ta- pregnancy (38–42 weeks) and should be in early active bles and bar graphs and clustered into 5 themes . phase of labour (cervical dilatation of 3–10 cm, regular The field notes and informal voice conversations were uterine contractions), with the presence of the foetal analyzed qualitatively through open coding and were heart beat. All the midwives who had at least two years’ mergered with the 5 themes. experience in the labour unit who agreed to participate in the study. The researcher sampled women and midwives . The sample comprised of 24 women and Ethical considerations 12 midwives. Ethical clearance was obtained from the Ethics Commit- tee of the University of Venda (SHS/11/PDC/001) and Data collection permission to access the health facility and conduct the Data were collected by researcher who is a holder of study from the Provincial Department of Health. The PhD in Midwifery and Neonatal nursing, during the day principles of informed consent, beneficence and right to shift in August – December 2015. The researcher was privacy were observed. Participation in the study was also shared the same culture and language with partici- voluntary and no remuneration was given. The consent pants. The researcher collected data through participant of participants was obtained before data collection. observations which included semi-structured observa- tional guide, observing the activities, interactions and conversations between the women and the midwives Results during intrapartum care (Additional file 1). The use of Theme 1: Communication between women and midwives participant observation gave additional and more accur- during labour ate information on behaviour of people . This Communication between women and midwives during semi-structured observation method enabled the re- labour was determined by observing the interactions and searcher to describe events and behaviour as they oc- activities as presented in Fig. 1: curred during labour . Observations were limited to the interaction between a woman and a midwife during Ability of midwife to empower the woman labour and the midwifery care rendered that is; commu- Enabling the woman to feel special and relaxed (by nication, informational support, emotional support activ- explaining the physiological changes and ities, physical comforting measures rendered and encouraging relaxation exercises) supportive care activities when the woman is experien- Advocacy skill cing labour pains. Observations were carried when a Determining the woman’s cultural and personal woman was in the active phase of labour, when the cer- preferences vical dilatation was 3 cm to the delivery of the placenta. Continuous updating on foetal and maternal The unstructured conversations were held informally progress Maputle BMC Pregnancy and Childbirth (2018) 18:210 Page 4 of 11 Fig. 1 Interaction/ communication between women and midwives The observation showed that (10) 83% of midwives attending midwives to mothers during childbirth, the where continuously updated the mother on maternal observed informational support as presented in Fig. 2, labour progress and on foetal well-being. Limited namely; affective communication was displayed which was thought to facilitate mutual participation as evidenced Answering of mother’s questions by (3) 25% of midwives advocating mothers when with Allowing/encouraging mothers to ask questions the doctor, (2) 17% of the midwives were able to em- Advising mothers on the physiological changes of power mothers, (3) 25% of the midwives were enabling labour the mother to feel special and relaxed and (1) 8% of the Offering mothers opportunities to come up with midwives determined the mother’s cultural/personal suggestions preferences. Some of the direct quotes from participants Extending advice and encouragement that indicate limited empowering during labour were Guiding and assisting mothers throughout delivery “my midwife was not telling me what is happening and I think she must be patient and at least listen to what I It was noted that (9) 75% of the midwives advised want to say”. With regard to determining the mother’s mothers on changes taking place during childbirth and cultural preferences, one participant said “Hmm … I guided and assisted them throughout childbirth. Actions didn’t clearly understand the language of the midwife”, that were promoting mothers’ participation were limited as so this indicated that cultural preferences were not de- only (4) 33% of the midwives extended encouragements, (1) termined. Another participant said “if I indicate the cul- 8% offered opportunities for mother to give suggestions tural preference she didn’t allow or even listen to why I whilst (1) 8% of attending midwives allowed mothers to ask was making such a preference.” questions which were answered during childbirth. The observation was supported by the direct quotes from a labouring woman who said “my midwife was tell- Theme 2: Informational support during childbirth ing me to breathe in and out but I didn’t know why.” From the profile of mothers recruited for the study This showed that midwives are giving advice and en- (Table 1), 23 (96%) did not participate in childbirth prep- couragement but not advising on the labour changes. aration classes. Only 1 (4%) mother participated in child- However, the other participant said “Midwives should birth classes, hence it can be inferred that mothers give me information, and then I would be able to probably had limited information support from the at- make choices. So as I’m updated with the progress of tending midwives during childbirth. To determine labour I’mabletomakeinformedchoices likerelax- whether informational support was given by the ation techniques.” Maputle BMC Pregnancy and Childbirth (2018) 18:210 Page 5 of 11 Table 1 Demographic profile of mothers and midwives recruited for the study Mothers N = 24 % Midwives N =12 % 1. Age in years on your last birthday 1. Gender 16–20 7 29 Male 0 0 21–30 12 50 Female 12 100 31+ 05 21 2. Parity: 2. Qualifications Primigravida 13 54 Registered midwife 10 83 Para 2–3 07 29 Advanced midwife 02 17 Para 4+ 04 17 3. Delivery outcome (exclude fetal deaths 3. Duration of allocation in labour ward - years Normal vaginal delivery 19 79 2–406 50 Forceps or vacuum extraction delivery 0 0 5–604 33 Caesarian section (not elective) 05 21 > 7 02 17 4. Duration of labour (hours) 4. Cultural/ Ethnic group 2–4 2 8 Northern Sotho 9 75 5–8 4 17 Tsonga 2 17 > 9 18 75 Venda 1 8 Others 0 0 5. Pain relief during labour 5. Religious affiliation Pharmacological 03 13 Protestants 4 33 Non-pharmacological 21 87 Apostolic church 2 17 Zion Christian church 2 17 Others 4 33 6. Cultural/ Ethnic group Northern Sotho 15 63 Tsonga 4 17 Venda 3 12 Others 2 08 7. Family status Married 10 42 Single 14 58 Divorced 0 0 Widow 0 0 8. Religious affiliation Protestants 14 58 Apostolic church 3 13 Zion Christian church 7 29 Others 0 0 9. Educational status Never literate 2 8 Primary school literate 5 21 Secondary school literate 9 38 Tertiary institution 8 33 10. Companion present? Yes 0 0 Maputle BMC Pregnancy and Childbirth (2018) 18:210 Page 6 of 11 Table 1 Demographic profile of mothers and midwives recruited for the study (Continued) Mothers N = 24 % Midwives N =12 % No 24 100 11. Participation in childbirth preparation classes Yes 1 4 No 23 96 12. Transfer from another hospital Yes 5 21 No 19 79 Theme 3: Emotional support during childbirth It was observed that midwives offered limited emo- To determine the emotional support given by the at- tional support during childbirth as evidenced by the ob- tending midwives to mothers during childbirth, the fol- servation that (0) none of the midwives encouraged the lowing were observed: presence of a companion and integration of cultural/ personal preferences during childbirth. Only (4) 33% of Instilling of confidence (with information provided) attending midwives showed respect for mothers during and encouragement of companion to be present labour whereas (3) 25% were encouraging free choice during labour and full participation of the mothers. A significant num- Be understanding, friendly and reassuring ber of attending midwives (8) 67% displayed an under- Encouraging free choice and full participation standing, friendly and reassuring attitude to mothers Fostering the integration of cultural/personal during childbirth. Figure 3 illustrates that only (4) 33% preferences of the midwives showed respect for mothers. Some mid- Show of respect wives were encouraging participation and this was Fig. 2 Informational support and exchange between mothers and attending midwives Maputle BMC Pregnancy and Childbirth (2018) 18:210 Page 7 of 11 Fig. 3 Emotional support activities by attending midwives during labour confirmed by one participant who said “When I was ex- All assessments were completed independently and periencing severe pain, she told me to lie on the side, sit without reference to the previous rating. Findings as pre- or adopt any position that I feel comfortable.” However, sented in Fig. 4. contrary to the observed friendliness and reassurance Findings on VAS on Fig. 4 indicated that mothers were the participant said “I would also be happy if the mid- experiencing severe pain throughout labour (with a pain wives can be more approachable, listen to what I say score 6–8), while the pain midwives exhibited (per- and not to be too harsh.” The other participant said ceived) was mild-moderate at the beginning of labour “During childbirth I expect midwives to be friendly and (2.5–4.5) but at the end of labour, the pain score was to respect me as an adult.” similar to that of mothers (9.5). Theme 5: Supportive care activities during labour Theme 4: Interpretation of experienced and perceived When the mother was responding to contractions dur- pain during labour ing childbirth, the following supportive care activities The visual analog scale (VAS, 100 mm tool) was issued were determined: to mothers and their attending midwives with the aim of comparing the pain experienced among mothers during Provision of physical care childbirth and to observe the awareness and responses Attendance to the elimination needs of the attending midwives to the pain exhibited by Midwife caring for more than one mother at the mothers. Mothers and their attending midwives had to same time complete the scale independently during the following phases of cervical dilatation: Figure 5 presents the findings of supportive care ac- tivities by midwives when mothers were experiencing 0–3 cm, mothers were experiencing moderate pain pain. while attending midwives perceived as mild pain All midwives provided care for mothers’ elimination 4–7 cm, mothers experienced severe pain while needs. Midwives could not give individual care to midwives still perceived this as mild pain mothers, as they were caring for more than one 8–10 cm, both groups experienced and perceived mother at the same time. There was a shortage of pain as severe. staff as (2) 17% of the midwives were caring for more Maputle BMC Pregnancy and Childbirth (2018) 18:210 Page 8 of 11 Fig. 4 Pain scores by visual analogue scale than one mother. Only (3) 25% of midwives provided Discussion physical care during childbirth (physical care include Five themes emerged as support provided by midwives touching, rubbing/ massaging). during labour, namely; communication between women The quotes from participants that supported the ob- and midwives, informational support, emotional support servation as cited by one participant was “the midwife activities, interpretation of the experienced labour pain was good to me, because she was assisting me with and supportive care activities during labour. It was noted my elimination needs, hence I was able to deal with that communication between the woman and the mid- my pain.” However, another woman said “Iamwait- wife occurred more when the midwife was rendering ing for that other midwife, as the one who was help- midwifery care and very limited during affective commu- ing me has left”. For this woman, the midwife was nication. Watkins  pointed out that determining caring for more women. women’s preferences for their care in labour is a Fig. 5 Supportive care activities by attending midwives during labour Maputle BMC Pregnancy and Childbirth (2018) 18:210 Page 9 of 11 reasonable basis for caregiving activities. Table 1 indi- single most reliable indicator of how much pain she is cates that from the total population of mothers (n = 24) experiencing . However, at the end of labour pain recruited in the study, 9 (37%) did not share the same score for both mothers and midwives was similar. Pain language with the attending midwives. Hindered verbal research indicated that midwives often assess patients’ communication as a result of language barriers and pain inaccurately [27, 29]. On observation of the mid- non-listening skills were displayed during the interaction wives’ responses to the mothers’ pain, the responses of a midwife and a mother during childbirth in this were similar throughout the childbirth process. The care study. Persson and Dykes  firmly supposed that the provided by midwives to the mothers when experiencing experience of good care appeared to be dependent on pain is displayed in Fig. 5. Very few mothers were given communication and behaviour to be able to meet analgesics as prescribed. Hodnett, et al.,  reinforced mothers just as they are. that labour support which is non-medical care of a Analysis of the observations in the informational sup- labouring woman, involves physical comforting such as port theme, (Fig. 2) revealed that during information touching, massaging, bathing, grooming, applying sharing between the mother and the midwife more em- warmth or cold Teshome et al.,  emotional support phasis was placed on the assistive actions than on the such as continuous companion, reassurance, encourage- activities that would promote mothers’ participation. ment, anticipatory guidance, information provision, and Bergstrom et al.,  indicated that women want infor- non-medical advice. Whereas Mackey ; Lundgren mation about pain and fear and how to mitigate both,  considered praise, flexibility, acceptance, informa- explanations about the instruments and processes in- tion giving, encouragement, friendliness, presence, confi- volved in birth, and positive communication. The dence, and assisting with breathing and relaxing to be amount and type of information sharing, to include ex- aspects of helpful nursing qualities during labour. planations about the process of birth, reports about des- cent of the foetus’s head, and soliciting information Limitations about the woman’s well-being. Bryanton et al.,  sup- Data was only collected during the day shift from 07 h00 ported that when women have more information about to 18 h00 the support provided by night shift staff could what is happening to and around them and are given op- have given different results. The use of participatory ob- tions about position changes and timing of pushing, they servations by semi-structured observational guide may can take control of the birth. have been influence observer preconceived ideas, which Rice  indicated that lack of respect and disregard may affect the results of the study. of the choices for mothers, in the mothers’ narratives, contribute to apathy towards respect in their treatment Conclusions and inability to exercise choices in decision-making. Re- The tertiary hospital was challenged with the shortage of spect empowers women . Results also indicated that staff and this contributed to one midwife to caring for none of the midwives encouraged the presence of a more than one woman at a time. Hence, midwives were companion during childbirth. Brown  wrote that the mainly providing care for mothers’ elimination needs. reasons for this restriction may include negative attitude The communication was occurring when the midwife of labour ward staff toward the presence of outsiders in was rendering midwifery care and very limited for the labour ward. In an incident during the study, one empowering. The information sharing focused on the as- midwife participant was very stressed and insensitive sistive actions rather than on the activities that would with an instructive attitude. She was also impatient to an promote mothers’ participation. The emotional support extent that little or no explanations were give during the activities indicated lack of respect and disregard cultural provision of care. Hence, the mother participant was ab- preferences and this contributed to inability to exercise solutely terrified as no comforting words were forthcom- choices in decision-making. Mothers were never given ing from the midwife participant. This resulted in analgesic during labour because the interpretation of ex- mother not co-operating as there was no gestures of un- perienced and the perceived pain by midwives were dif- derstanding between the two. ferent, and mothers were perceived to be in severe pain The VAS is one of the most used pain assessment in- when the cervical dilatation was 9–10 cm. The presence struments, both in research and clinical practice . of companion was not encouraged, hence physical care With the VAS, mothers were experiencing severe pain include touching, rubbing/ massaging were limited. The throughout labour while the pain perceived by midwives study recommended the implementation of Batho Pele was mild-moderate. This was supported by Baker et al. principles in order to provide woman-centred care dur-  who found that midwives were less able to assess ing labour. pain accurately when women described their pain as se- The recommendations were aimed at improving the vere. The patient’s verbal report is considered to be the standard of the public service and effective service delivery Maputle BMC Pregnancy and Childbirth (2018) 18:210 Page 10 of 11 to support women during labour. Services should be Ethics approval and consent to participate The study was approved by the Human research Ethics Committee of the based on a customer-orientated framework. These princi- University of Venda (SHS/11/PDC/001). Participants gave written informed ples were integrated within the framework to provide consent for their participation which included consent for observation woman-centered care as follows: semi-structured observation, unstructured conversations/ interview and anonymous reporting of person details such as demographic profile. Midwives are to consult mothers about the level of Competing interest midwifery care to be received and, where possible, The author declares that she has no financial or personal relationship(s) which may have inappropriately influenced her in writing this article. should give (allow) involvement and support choices about the services that are offered (consultation). Publisher’sNote Mothers should be told what level and quality of Springer Nature remains neutral with regard to jurisdictional claims in midwifery care (intervention are to be provided so published maps and institutional affiliations. that they would be aware of what to expect (service Received: 26 October 2016 Accepted: 25 May 2018 standard). Mothers are to be treated with courtesy and consideration; they should be allowed to practice References 1. Department of Public Services and Administration. White paper on their preferences during childbirth (courtesy). transforming public service delivery, Government Gazette 388 (18340), Midwives should allow all mothers equal access to Government Printer, Pretoria. 1997. personal control and decision-making (access). 2. Raphael-Leff J. Psychological processes of childbearing. 4th ed. Guildford, UK: Anna Freud Centre; 2005. Mothers should be given full and accurate 3. Lundgren I. Releasing and relieving encounters. 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