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Midwives’ experiences of managing women in labour in the Limpopo Province of South Africa

Midwives’ experiences of managing women in labour in the Limpopo Province of South Africa Research Article Midwives’ experiences of managing women in labour in the Limpopo Province of South Africa SM Maputle, D.Cur Senior Lecturer, University of Venda: Department of Advanced Nursing Sience DC Hiss, PHD (Medicine) Professor, University Western Cape: Department of Medical Biosciences Key words Abstract: Curationis 33 (3): 5-14 Accommodative midwifery actions; Introduction: The objective of this study was to explore and describe the experiences maximisation of human and material in- of midwives managing women during labour at a tertiary care hospital in the Limpopo frastructure; collaboration; interde- Province. An exploratory, descriptive, contextual and inductive design was applied pendence and mutual participation. to this qualitative research study. Purposive sampling was used to select midwives who were working in the childbirth unit and had managed women during labour. A sample of 12 midwives participated in this study. Data were collected by means of unstructured individual interviews and analysed through an open coding method by the researchers and the independent co-coder. Findings: Categories identified were lack of mutual participation and responsibility sharing, dependency and lack of decision-making, lack of information-sharing, em- powering autonomy and informed choices opportunities, lack of open communica- tion and listening, non-accommodative midwifery actions, and lack of human and material infrastructure. To ensure the validity of the results, criteria to measure trustworthiness were utilized. Conclusions: This study has implications for woman-centered care by midwives managing women in labour and provides appropriate guidelines that should be inte- grated into the Batho-Pele Principles. Correspondence address Dr S. Maputle Private Bag X 5050 Thohoyandou Tel: (015) 962 8125 Fax: (015) 962 8647 E-mail: [email protected] Curationis September 2010 further separates the mind from the within this legal framework is that of Introduction body. The biomedical model and its Batho-Pele “People First”, implying that Midwives form the backbone of mater- dominant effect on healthcare have led the consumer of healthcare is placed at nal, child and women’s health in South to it being used in the interest of mid- the centre of healthcare delivery. It also Africa. Their caring for women during wives, for example, the model concen- means that healthcare delivery is trans- childbirth is a unique life event that is a trates information and decision-making formed in such a way that consumers core function of the midwifery profes- to doctors and midwives, and to a lesser are satisfied with it (Department of Pub- sion. Midwives play a vital role in the extent to women in labour. The mod- lic Service and Administration, 1997). implementation of the Batho Pele Prin- el’s emphasis is more on high technol- Sandall (1995:201) supports customer- ciples, Patients’ Rights Charter and ogy that inherently leads to the loss of oriented service delivery based on the Millennium Developmental Goals personalized and compassionate hu- philosophy that focus should shift from (MDGs). However, limited studies fo- man care. Women in labour are labelled technologisation to personalisation, cused on the experiences of midwives according to diagnosis rather than be- and thus to the creation of the para- managing women during labour. This ing known as patients with needs to be digm of a woman-centered practice study explored and described the ex- attended to. At the same time, Pearson based on equal partnership between periences of midwives who manage et al. (1998:37) affirm that the biomedi- women in labour and midwives. women in labour in a tertiary hospital cal model is well developed and un- in the Limpopo Province. doubtedly gives direction to midwifery Problem Statement practice, which is useful. The pressure When mothers are admitted to labour Background from society and increased understand- wards, midwives seem to focus mainly Childbirth, from the perspective of the ing of human rights through the Pa- on completing certain tasks before biomedical model (Pearson, Vaughan tients’ Charter and Batho-Pele Princi- handing over the report to the next mid- and Fitzgerald (1998:36), focuses on the ples have highlighted the restrictive wife on duty. Little effort is thus ex- physiological changes that take place nature of the biomedical model, the al- pended on meeting the needs of women during childbirth and the specialized ternative approach being the provision in labour as individuals. When man- scientific knowledge midwives possess of woman-centred care. The Batho- aging women in labour during child- with regard to these changes. The key Pele Principles seek to introduce a cus- birth, midwives follow a set of stand- focus of this model is on the manage- tomer-focused approach that aims to ards and procedures to monitor and ment of labour and the detection of put pressure on systems, procedures, regulate physiological developments. complications or normal childbirth. attitudes and behaviours within the Women in labour, too, are expected to The situation in hospitals that provide childbirth units and orient midwifery follow the set standards and midwifery childbirth care is such that prescribed practice towards the needs and advan- protocols. While these policies and routines are frequently adhered to as tages of customers, an approach which procedures might make sense from the laid down in the policies and proce- puts people first (Department of Public standpoint of midwifery care and pos- dures strategically placed in the ward. Service and Administration, 1997). The sibly also reflect the priorities dictated Midwives generally regard it as their White Paper further indicated that this by the biomedical model, they do not responsibility to ensure that this code does not necessarily mean introducing always manifest the experiences, needs of conduct is not breached. Pearson et more rules and centralised processes, and priorities of women in labour dur- al. (1998:34) indicate that the end re- or micro-managing service delivery ac- ing childbirth. Also, the experiences of sults of such an approach are stand- tivities. Rather, it involves creating a midwives facilitating active participa- ardised routines for maternal care dur- framework for delivery of public serv- tion and decision-making of women ing childbirth. They further point out ices which treats citizens more like cus- during childbirth are not well docu- that women in labour are often expected tomers and enables them to hold pub- mented. In view of this paucity, the to comply with a predictable pattern lic servants to account for the services present study sought to determine the and follow the routine laid down by the they render. Healthcare institutions midwives’ experiences of managing regulations. Such standardised rou- ought to create a people-centered and women who are in labour at a tertiary tines have some merit, but when fol- people-driven service that is character- hospital in the Limpopo Province. lowed without skilled assessment may ised by equity, quality, timeousness and pose a risk of depersonalising the a strong code of ethics (Revere & women in labour and discouraging any Black, 2003: 380). The White Paper on Research Question participation and involvement during Transforming Service Delivery (The The following research question midwifery care. This leads to the de- Department of Public Service and Ad- guided this study: What are the mid- valuation of acts related to how women ministration, 1997) through the eight wives’ experiences of managing women in labour experience their own child- Batho-Pele Principles (consultation, during labour at a tertiary hospital in birth, such as listening, comforting or service standard, courtesy, access, in- the Limpopo Province? offering choices. Thus, this model is formation, openness and transparency, not completely geared to meet the spe- redress and value for money) aims to Purpose Of The Study cific needs of women in labour. Pearson improve the entire standard of the pub- The purpose of the study was to ex- et al. (1998:36) view the biomedical lic service and the effectiveness of plore and describe the midwives’ expe- model as a reductionist and dualistic service delivery. Services should be riences of managing women during la- approach because it reduces the hu- based on a customer-orientated frame- bour in a tertiary hospital in the man body to a set of related parts and work. The guiding principle adopted Curationis September 2010 Limpopo Province. The findings of this Capricorn, Mopani, Vhembe, adequate only after sufficient data had study were used to develop the woman- Sekhukhune and Waterberg. As indi- been collected, saturation had occurred centered childbirth model (not de- cated in the Department of Health Re- and variation had been accounted for scribed here) and guidelines that are port (2005:52), the total population in and understood. Saturation means that integrated within the Batho-Pele Prin- the province is estimated at 5 514 mil- no new or relevant data seem to emerge ciples It is hoped that these guidelines lion of which females constitute 54%. for a particular category (Strauss & would assist midwives in the facilita- Of the total female population, 45% was Corbin, 1990:188). Twelve (12) mid- tion of mutual participation when man- in the childbearing age group. The wives had been sampled when satura- aging women during labour. health service structure in Limpopo tion was achieved. Province consists of 1 tertiary institu- tion, 6 district hospitals (level 2) and 36 Data collection Definitions Of Terms community hospitals (level 1). Of the Permission to gain entry into childbirth Concepts used in this study are defined 43 hospitals, 40 has functional mater- units was obtained following approval as follows: nity units for deliveries and an esti- from the Ethics Committee of the Uni- mated 64% of the total number of births versity of Johannesburg, the Provin- Experience occur in these hospitals. The tertiary cial Department of Health, and the hos- Experience is an event or circumstance hospital is a referral hospital for levels pital concerned. The project was ex- undergone or lived through (Oxford 1 and 2 hospitals within the province. plained to the unit managers and mid- English Dictionary, 2005). In this study, The current trend is that more women wives in the obstetrical wards. Written experience refers to all the circum- are giving birth in hospitals than at informed consent was obtained from stances that take place between the home in the Limpopo province (Depart- the midwives. A pilot study was con- midwife and the mother during child- ment of Health Report, 2005:52). ducted with 6 midwives to refine the birth. question (Burns & Grove, 2005:38). The aim was to see whether the question Research Methodology In labour was clear to the midwives. Midwives In this study, in labour refers to the proc- Procedure of research understood the question and the inter- ess when a woman gives birth to a child The research design was qualitative, views were conducted successfully. and the midwife managing her. The exploratory, descriptive and contextual The question and interview procedure process includes the first, second and (McLeod, 2001:54-56), and aimed to were not changed. These midwives third stages of labour. provide a description and an explora- were not included in the main sample. tion of a particular phenomenon or ex- Data were collected by means of un- Biomedical Model perience within the context of the phe- structured phenomenological in-depth Biomedical model refers to the model nomenon’s specific setting and world interviews (Burns & Grove, 2005:130). on which midwives base their practice. significance by using a The unstructured question directed at In this model, women in labour (pa- phenomenological approach. Phenom- the midwives was: “Could you please tients) are viewed as biological beings enology is a philosophy and method tell me about your experiences of man- and little attention is paid to the wider which stresses the importance of de- aging women who are in labour?” characteristics of their human nature scribing and understanding human ex- (Pearson, Vaughan & Fitzgerald, The interviews were conducted by the perience as it is lived, before theoris- 1998:27). In this study, the biomedical researcher in the labour ward’s rest ing it (Gu, Zhang & Ding, 2009). model refers to the midwife taking full room (quiet place), did not exceed 45 responsibility for controlling the child- minutes and were generally completed Population and sampling birth process without the mother’s par- within 24 hours of managing and con- The population consisted of all mid- ticipation and sharing responsibility. ducting a delivery. The interviews were wives who were managing women who conducted in English, tape-recorded were in labour in the obstetric unit of a Meta-theoretical and midwives assured that sensitive tertiary hospital in the Limpopo Prov- ethical issues such as maintaining con- Assumptions ince. Non-probability, convenience fidentiality of data and preserving the and purposive sampling were used in The meta-theoretical statements of the anonymity of the participants as well the study. The researchers conven- Batho-Pele Principles (Department of as using research for its intended pur- iently sampled the available midwives Public Service and Administration, poses will be strictly observed (Polit, who were providing midwifery care to 1997) were used as a frame of reference Beck & Hungler, 2001:73-89). women in labour during the active in this study, with emphasis on putting phase of labour (3 – 10 cm cervical dila- women in labour first with midwives Ethical considerations tation). Purposive sampling is a type facilitating mutual participation during The ethical standards as set by Demo- of non-probability sampling in which this process. cratic Nursing Organization of South data are collected from a group of par- Africa (DENOSA) were adhered to be- ticipants chosen for specific key char- Research Methodology fore and during the interview acteristic (Sells, 1997:172). All midwives (DENOSA, 1998:1-7). Privacy was en- Context who had at least two years experience The study was conducted in a tertiary sured during the interview. The par- in the obstetric unit and who had care hospital in the Limpopo Province ticipants were assured that their par- agreed to participate were sampled. In which consists of five districts, namely, ticipation was entirely voluntary and this study, the sample was considered Curationis September 2010 that they could withdraw from the re- Table 1: Categories that emerged from analysis of midwives’ search project at any stage if they felt experiences of managing women who are in labour like doing so. During the interview, communication skills, for example, prob- ing, were used to obtain the necessary Category Description information. Unstructured conversa- tions with midwives were held infor- 1. Limited mutual participation, responsibility-sharing, decision- mally throughout the labour phases. making and dependency These conversations were spontane- ous and emerged from natural social 2. Lack of information-sharing, empowering, autonomy and informed interaction, and contributed to the choices depth and richness of information that otherwise would have been difficult to 3. Limited open communication and listening capture through more structured inter- views. Field notes of events and con- 4. Non-accommodative midwifery actions versations that occurred when women in labour interacted with their midwives 5. Limited human and material infrastructure were recorded verbatim. Data analysis cal area; the researcher conducted the comfortable with their dependency on Data analysis is a process of bringing unstructured interviews until data satu- the midwives as they indicated that order to the data, organising what is ration occurred, that is, until the col- midwives were trained practitioners and collected into concepts, categories and lected data were repeated and confir- knew what is best for them. Since the basic descriptive statements (Marshall mation of previously collected data had women in labour depended on mid- & Rossman, 1999:111). Tape-record- taken place. Furthermore, categories wives, it was evident that they had lim- ings of the interviews were transcribed identified by the researcher were com- ited decision-making capability. Bluff verbatim in the language in which the pared with those pinpointed by the and Holloway (2008: 308) affirmed that interviews were held. The narrative other coder and no major discrepan- women often place themselves in the cies were observed. An in-depth lit- data from unstructured in-depth inter- hands of midwives and allow midwives erature review further confirmed these views were analysed qualitatively to make decisions for them, even if their categories. This enhanced through the open coding method to own wishes are neglected. confirmability. Transferability was en- develop categories (Tesch, 1990, cited sured by the researcher via data analy- in Cresswell, 2003:192). The independ- Fabian, Rádestad and Waldenstrõm sis, interpretation and in-depth discus- ent researcher was also requested to (2008: 230) further indicated that mid- sions in a research report. analyse the data according to the open wives are challenged to enforce equal coding method. The two analyses were opportunities to make information available and to encourage women in then compared to ensure trustworthi- Findings And labour to take responsibility for their ness. The selection of the analyser was Discussions own care. Gibbins and Thomson based on experience in qualitative re- Five categories emerged that described (2001:310) argued that being included search methodology. the experiences of midwives who are in and making decisions are reported managing women during labour at a as being crucial in helping women feel Trustworthiness tertiary hospital in the Limpopo Prov- in control during labour. According to The four criteria of trustworthiness, ince (Table 1). midwives interviewed, women in labour namely, credibility, dependability, trans- accepted (without questioning) deci- ferability and applicability, as outlined Category 1: Limited mutual sions made by the midwives. This in Lincoln and Guba (1985:301-318), stance placed the midwife in a position participation, responsibility- were used to establish the trustworthi- of power and authority to make deci- sharing, decision-making and ness of this study. In this study, cred- sions. However, in other instances the ibility was enhanced by the following dependency mother did not understand why certain considerations: the researcher had pro- Midwives were of the opinion that dur- decisions were made, but she still com- longed exposure to the field of study; ing labour women did not verbalise that plied because of the trust she put in the researcher is a midwife, who has they would like to participate in deci- the decision-maker, regardless of what knowledge and clinical experience in sion-making. Instead, women followed the decision entailed. Ritcher, Greaney, this area of expertise; the literature con- instructions of midwives. Lundgren McKeown and Cornell (2001:174) sup- sulted enabled the researcher to sat- and Dahlberg (2002:158) pointed out ported this contention by indicating isfy the criterion of being knowledge- that it is important for midwives to col- that participative decision-making re- able about the phenomenon under in- laborate with women in labour by in- quires patients be knowledgeable vestigation; the researcher bracketed viting them to participate and be re- about their healthcare. This means that existing knowledge and preconceived sponsible for their care during child- they should have the ability to proc- ideas, and especially personal views, birth. Midwives also indicated that ess medical information and under- about the existing problems in the clini- some of the women in labour were stand the outcomes of choices they Curationis September 2010 make. showing respect, and clarifying each Rádestad and Waldenstrõm (2008: 233). Providing midwifery care is potentially other’s expectations through the pro- Midwives have the capability of assist- stressful when women are not partici- vision of information on childbirth is- ing women in labour to contextualize pating in their care during childbirth. sues and available options. This sup- the information, by creating a relation- Midwives were of the opinion that port will facilitate an environment that ship of trust through respect. How- women in labour do not participate at is conducive to women becoming more ever, Pope, Graham & Patel (2001:238) all in their care and that they displayed involved and participating willingly in cautioned that there are some indica- limited responsibility-sharing and de- their midwifery care. In woman-cen- tions of stereotyped views. cision-making during childbirth. These tred care, the midwife should take the Midwife participants pronounced that sentiments were supported by one mid- following into consideration: kindness women in labour lacked accurate infor- wife, “The mother may not, however, and respect, listening care, a share in mation or knowledge about the under- be willing to participate in her care decision-making, and the opportunity standing and awareness of what should for various reasons. Some maybe un- for a woman to talk about her care. This happen during childbirth. During child- prepared for childbirth or maybe she approach would facilitate participation birth it was evident that women in la- had not discussed aspects of partici- during childbirth. bour with accurate and up-to-date in- pation during pregnancy.” Two other formation with regard to childbirth is- midwives indicated that “Women in sues and the available options were able Category 2: Lack of labour very easily put themselves into to make informed choices. The follow- information-sharing, the hands of the midwives. I don’t ing excerpt from the interviews exem- empowering, autonomy and know what the cause is or is it because plifies this statement, “When informa- informed choices there were no discussions regarding tion was shared with regard to child- Midwives expressed the opinion that responsibility during pregnancy? But birth issues and available childbirth women lack information regarding the at times there is an attitude in our so- options had been outlined, the women childbirth process. Gibbins and ciety that says a pregnant mother is ill in labour would be empowered.” One Thomson (2001:302) stated that there and must leave all the responsibility midwife participant who managed are many expressions of the need for to the midwives because they know women who lacked information said, information, reassurance and confi- best.” This was viewed by midwives “Most women who are in labour look dence-building. They further pointed as a ‘dependency syndrome’. Mid- confused and don’t listen to the in- out that information given during child- wives also felt that women were not structions carefully. They are anxious birth enables the mother to take deci- cooperating during labour. and don’t co-operate.” Another mid- sions and empowers her to make in- Midwives were also of the view that wife participant said, “Women in labour formed choices. In addition, Richter et their roles were to support the deci- seemed to be lacking information, al. (2001:174) asserted that if women sions of women during childbirth and some will even refuse to be done vagi- were not given adequate information, that the mother’s participation could be nal examination during labour. Primi- they might not be able to collaborate strengthened if a therapeutic environ- gravidae are worse because they close with their physicians or be willing or ment was created. One midwife partici- the thighs when the head crowns, but able to ask questions. Lack of shared pant exemplified this by describing how those with little information on what information was thus an obvious con- she supported the mother by explain- is going to happen, they are better, cern. Sharing of information in advance ing all procedures to her and promoted they do co-operate.” It was evident could build the necessary trust so that her participation by indicating that she from the transcripts of interviews with goals could be consciously adapted had to come up with her preferences midwives that limited information with throughout the childbirth process. Lim- for childbirth, and encouraged her to regard to childbirth issues, available ited information, ideas and options are ask questions. The following direct childbirth options and understanding often cited as reasons why women are quotations from the midwife support what should happen during childbirth socialised to accept pain as their lot in this notion: “Although women in la- contributed to limited capacity to make life (Mahmoud, 2006: 412). Gibbins and bour did not indicate their behaviour informed choices during childbirth by Thomson (2001:302) suggested that as preferences, they nevertheless par- the women. information given during childbirth ticipated by adopting a squatting po- enables the mother to take decisions sition during childbirth.” Another Category 3: Limited open and empowers her to make informed midwife participant said, “You know communication and listening. choices. This idea is supported by the some women are from a cultural envi- Communication between a midwife and concept that women need to be given ronment where the woman is not used a mother during childbirth should be information and the opportunity to dis- to expressing her wishes as this is not open and effective. Both parties should cuss how that information relates to allowed. For example, if the partner understand the language of the other. their particular circumstances. The is available during childbirth, when Midwife participants were of the opin- same concept is reinforced by the as- asked her wishes, she will look at the ion that women in labour are made to sumption that information builds con- partner and expect him to decide.” feel free to verbalise their thoughts and fidence and self-esteem which would Midwives could support and give wishes during childbirth. They further enable the mother to take control over women in labour the opportunity to indicated that they are being open, her childbirth, ask questions, make in- participate and be responsible during formed choices and communicate more supportive and that they listen to childbirth by being open, listening to women and understand their unique women, explaining all procedures, effectively with midwives (Fabian, Curationis September 2010 circumstances and their wishes. From (1991) in the study “Midwife/Client deemed that they promoted, supported the transcripts of interviews with mid- Relationship: Midwives’ Perspec- and respected the values, beliefs and wives, language barriers were cited as tives”, as cited in Doherty (2010:98). preferences of women as long as they a factor that interfered with their inter- The authors observed that women in were not harmful to the mother and action with women during childbirth. labour did not listen to midwives, and baby. They were also convinced that This was the case, especially with this led to a feeling of worthlessness. some women in labour had unrealistic women who were transferred from other The midwife just went through the choices, which could not be accommo- process of helping the mother, but no hospitals and who spoke a language dated by midwives. One midwife par- mutual trusting relationship was estab- different from that of the midwife. The ticipant said, “I accommodate women’ lished. hospital under study provided mid- preferences, for example, squatting, Takayama and Yamazaki (2003) recog- wifery care for all racial groups. Mid- but if I find difficulties in managing nised the need for effective patient- wives cited that women in labour the childbirth, I explain to the mother physician communication in childbirth. viewed them as being impatient; that the benefits of adopting the dorsal This is referred to as mutual participa- they did not listen; and seldom veri- position and guide her in adopting the tion and consultation. Lothian, fied why women in labour had specific position”. Fabian et al (2008: 232) sug- 2006:297outlined the potential benefits preferences. One midwife participant gested that women need to be given of a birth plan (woman-centred care) said that, some women who are in la- information and the opportunity to dis- with regard to communication as fol- bour are difficult and are unable to cuss how that information relates to lows: improved channels of communi- follow instructions, especially if they their particular circumstances before cation between the caregivers (mid- don’t understand the language.” In the stresses of labour make it unrealis- wives) and the consumers (women) and instances where the midwife spoke a tic to enter into detailed considerations creation of opportunities for discussion different language, physical presence of the pros and cons of childbirth. of preferences. To the researchers, and touch were found to be beneficial Some women preferred to have their these benefits would enhance effective as corroborated by one midwife par- partners present during labour, which communication during childbirth. A ticipant, “The midwife’s physical pres- is encouraged, however, midwives had birth plan that involves a midwife can ence helps to establish some contact variable preferences and views regard- give pregnant women information to with the mother if the midwife and ing the presence of a partner during make choices and help them feel more mother are not sharing the same lan- childbirth. One midwife responded, “I confident (Lothian, 2006:297; Berg, guage.” Communication is key during allow the presence and support of the 2005: 20). Effective communication will childbirth. Lack of effective communi- partner during delivery because if the then lead to openness and conveyance cation between a midwife and a mother companion is present during child- of safety. According to Lundgren and may lead to the midwife failing to give birth he will support by soothing and Berg, (2007:149); Lundgren and Berg a clear explanation about the childbirth massaging to the mother.” According (2005:226), a trusting relationship de- process. Language difficulties and lack to Lundgren and Dahlberg (2002:158), velops that mediates a feeling of of information and clarification on the the presence of the father interfered tranquility and security. The woman part of the midwife also contribute to with their contact relationship with the can relax and feel that she is participat- misunderstanding and mother. This view was echoed by one ing in decision-making and thus gain miscommunication (Ito & Sharts- midwife, “The presence of a compan- some measure of control of the situa- Hopko, 2002:673). In support of this ion/partner during childbirth is an tion. The emotional aspect of the view, Ito and Sharts-Hopko (2002:673) obstacle to good a relationship. It is mother thus becomes supported. Open argued that due to lack of English com- very difficult to establish contact with communication and listening leads to munication with caregivers, women feel the mother in the presence of the fa- a relationship of trust during midwifery that they do not have anything to do. ther who at times displays negative care. One midwife participant indicated He further indicated that women do not attitude, worry or is aggressive.” An- that she was firm and honest with understand the midwife and are there- other midwife corroborated this feeling, women during labour in order to build fore unable to ask any questions dur- “The presence of the partner interferes a relationship of trust, “I think it is ing childbirth. Limited listening skills with the mother’s decision, especially important for us midwives to make it lead to ineffective communication. The in cultures where husbands are the clear to women in labour, under our midwife should display openness, decision makers. In one incident, when care, for example, by indicating that which is a sign of willingness to listen, the mother was asked about her it is important for me that you have a observe and understand. In some in- wishes, she looked at the husband and good childbirth, I’m available for you, stances, women felt that some proce- asked him to decide. This made me I care for you, but you are not the only dures were imposed on them. This feel that I can’t do anything about patient for me, you are my patient right observation is in agreement with a re- that.” Several authors have spelt out now.”. Communication is critical to ef- port by Viisainen (2001) that the way clearly the advantages of the presence fective caring during childbirth. interventions and processes are intro- of a companion during childbirth duced are usually in an authoritative (Somers-Smith, 1999:105 cited in Category 4: Non- or non-listening manner, which contrib- Maputle & Nolte, 2008). However, in accommodative midwifery uted to women in labour feeling dis- most parts of the world, childbirth is actions turbed. On the other hand, midwives still regarded a predominantly female Pertaining to the issues of being ac- also showed concern for the mother as issue, and in the vast majority of tradi- commodative, midwife participants is discussed by McCrea and Crute tional cultures it is unbecoming of men Curationis September 2010 to be present at birth (Fabian et al, 2008: that the participants have virtually the in terms of which are relevant and eas- 235). Midwives raised different opin- same power, that they need one another, ily understood by women in labour ions with regard to physical comfort that the shared activity will be satis- (women should be able to judge for during childbirth. According to Bluff factory to both, and that both become themselves whether they are receiving & Holloway (2008: 308), women in la- active participants in the development what was promised). Service standards bour regard midwives as the practition- of the nursing care plan (Pera & Van should cover the women in labour’ main ers of normal midwifery because “they Tonder, 1996: 58). To realize the Bill of requirements, for example, access (lan- know best”. Rights, the Batho-Pele Principles, as a guage), courtesy (respect) and provi- Government initiative to put people sion of information (education). first, will be adapted in order to facili- Women in labour must know and un- Category 5: Limited human and tate mutual participation between derstand what quality of service they material infrastructure women in labour and attending mid- can expect to receive and what re- Midwives were not able to spend qual- wives during childbirth as follows: sources they have if the standard is ity time with the women during labour not met. The midwife should create to verify their preferences. A shortage opportunities to inform the mother Consultation of staff was cited in the interview tran- about the investigations, procedures Facilitation of consultation and scripts. It was pointed out that one and results of childbirth and explain participative decision-making are aimed midwife might be caring for more than (communication) the reasons where the at the establishment of the childbirth two women at the same time. Pelkonen, service has fallen short of what was education programme, which is a cli- Perala and Vehvilainen-Julknnen promised. ent-centred process that builds confi- (1998:22) have found that a busy and dence and self-esteem to enable women routine atmosphere inhibits participa- in labour to take responsibility and con- Access tion, whereas a friendly, peaceful and trol over their childbirth as active part- The ‘White Paper on Transforming secure environment provides opportu- ners. It provides a platform for them to Public Service Delivery (1997) states nities for participation. Tarkka, ask questions and seek information so that the service delivery programme Paunonen and Laippala (2000:188) cited that they can make informed choices should address the needs of all citizens in Maputle and Nolte, 2008) agreed that and communicate effectively with the to progressively redress the disadvan- in order for midwives to influence posi- attending midwives (Nolte, 1998: 116). tages of all barriers to access. During tive childbirth experiences, they should The goal of childbirth education pro- the provision of midwifery care, barri- display empathy, friendliness, tender- grammes is to provide women in labour ers to access should be taken into con- ness, calmness, alertness, peacefulness with useful information on childbirth sideration in order to facilitate mutual and professional expertise towards to acquire a sound knowledge to chal- participation as follows: The attitude women in labour. However, staff short- lenge the rationale of some of the pro- ages tend to jeopardize this positive of the midwife should be approachable; cedures they are expected to undergo. contribution and often lead to a feeling the midwife should respect, encourage The childbirth education programme is of tension in clinics and wards. and support the mother’s cultural and the movement that focuses its atten- personal preferences and choices; the tion on teaching women the medical style of language and choice of words Recommendations definitions surrounding birth and to used by the midwife should be care- The proposal was to create a paradigm prepare women in labour for hospital fully considered because words can of woman-centred care that is based experiences. When the mother plans reflect attitudes of respect or disrespect on equal partnership between the mid- to fall pregnant or when she is preg- inclusion or exclusion, judgment or ac- wives and the women who is in labour. nant, she needs to consult with a mid- ceptance, i.e., choice of words can ei- The woman-centered care would be wife who will encourage her to attend ther ease or impede communication; integrated in the Batho-Pele Principles. the childbirth education programme. and encouragement of decision-mak- Guidelines to enhance the facilitation The midwife ought to create opportu- ing, autonomy, informed choices and of mutual participation (interdepend- nities for the mother to become a part- personal control (except in situations ence) were formulated. Chapter 2 of ner. The techniques chosen for a par- of clear health risk). the Constitution of South Africa, ticular mother will be based on needs through the Bill of Rights, gives citi- assessment. During consultation, the Courtesy zens the right to take action against the midwife is expected to respect the Midwives have a powerful effect on state if they believe their constitutional women in labour’ past experiences, women who are giving birth. They rights had been infringed upon. It also plans and needs with regard to their should be aware that their power to in- states that they have the right to ac- childbirth options. fluence impacts both positively and cess information held by midwives negatively on the mother’s childbirth which they need in order to participate Service standard experience. Women in labour tend to in decision-making, exercise informed Service standards are commitments to remember the specific words and ac- choices, and enjoy the benefits of au- provide a specified level and quality of tonomy, empowerment and independ- tions of midwives and their satisfac- service to individual customers at any ence (The Constitution, 1996:15). In tion is linked to the type of care re- line with these Constitutional princi- given point in time (Department of Pub- ceived, feelings of personal control and ples, the facilitation of mutual partici- lic Service and Administration, 1997). accomplishment. Midwives are ex- pation is based on the assumptions Service standards should be expressed pected to treat all women with cour- Curationis September 2010 tesy, respect and dignity during child- free of jargon -it should be supported ized by mutual trust. They further birth. When women in labour are by visual aids and other graphical ma- pointed out that trust forms the basis treated with courtesy and respect dur- terial (e.g., slides, films and videos) to of a successful and effective healthcare ing childbirth, they participate actively clarify the verbal information and to relationship. in their care. The following actions facilitate understanding ,however, cul- could be implemented to ensure that tural relevance should also be consid- Conclusion courtesy is taken into consideration: ered; handouts on specific topics could From the results of the interviews, it the Unit Managers should ensure that be supplied as a method of informing would appear that the tertiary hospital the values and behavioural norms of women during childbirth; information in the Limpopo Province has midwife- the units are in line with the Principles about the available services should be centred care rather than woman-cen- of Batho-Pele; the performance of mid- communicated to women in labour; tred care during childbirth. In midwife- wives who are in contact with women when all relevant information has been centred care, the midwife tells the during labour must be regularly moni- made available to the mother for the women what to do and how to behave. tored and recorded; opportunities achievement of her goals, she should The approach during childbirth was should be provided to midwives to sug- be guided and not directed by the mid- characterized by limited mutual partici- gest ways of improving midwifery care; wife to share the responsibility for her pation and responsibility-sharing. This the training programme that includes care during childbirth; information comprised of inadequate participation, day-to-day guidance should be devel- shared between the mother and the limited decision-making scope, a pro- oped in order to ensure that Batho-Pele midwife is valued by women in labour. liferation of practices that fostered de- Principles are implemented in the child- Maputle and Nolte (2008: 60) indicated pendency, and a prevailing authorita- birth unit; and it is proposed that the that women viewed attending of classes tive approach within the childbirth unit. midwife who renders care to the mother as a type of insurance because it ena- The strict routines that were laid down on admission in the hospital be the one bles them to feel more secure and in- by the regulations seemed to deperson- who delivers the mother in order to formed. The content of childbirth edu- alise the mother, thus resulting in her strengthen the relationship of trust. cation programmes should be adapted non-participation. Midwives imposed to the needs of the mother and could their authority and responsibility to cover the following: anatomical, physi- Information ensure that the rules were adhered to. ological, psychological and emotional Sharing information is a mutual respon- changes during pregnancy, labour and sibility of the midwife and the mother. pueperium, including changes that Women who are in labour were seen The consultation process should be could affect the partner; prevention merely as the ones who should comply used establish what women in labour and early detection of complications of with the rules of the unit while having need to know and where and when the childbirth; and management and care no decision-making power. There was information can be best provided. This of minor illnesses encountered during also an over-reliance on technology. could be achieved through the follow- pregnancy, labour and pueperium; pain Limited information-sharing and em- ing actions: the midwives should pro- relief during labour; orientation with powering were displayed in this ap- vide accurate and up-to-date informa- regard to the physical surroundings of proach. Information regarding child- tion about the childbirth process, ex- the labour ward, different techniques birth issues and awareness of available plain it fully by presenting the pros and used in hospital, basic routines of the options was not shared with the women cons about the care they would pro- hospital and all other aspects of preg- in labour. This resulted in a feeling of vide; when providing information, in- nancy, labour and pueperium (adapted powerlessness and a lack of autonomy dividual or group teaching methods from Nolte, 1998:120). However, Fabian should be adopted; relevant informa- in childbirth care. Hindered or ineffec- et al (2008: 234) is of the opinion that it tion should be provided in the womens’ tive communication, such as, inad- is very unlikely that the childbirth edu- own language (access) in order to meet equate listening skills of attending mid- cation programme, as it is currently of- the needs of the mother; the informa- wives and the existence of a language fered, is making a significant contribu- tion should be made simple in order to barrier between women and midwives tion towards putting most women at maximize its comprehension and pre- often resulted in limited participation the centre of their own care and ena- vent any potential imposition of the by the women in labour. The midwife- bling them to participate in decision- attending midwife’s view; when pre- centred care approach was confined to making about the management of their senting information to women in labour, the physiological processes of child- childbirth. an interval should elapse between the birth while the psychosocial aspects presentation of advantages and disad- of the mother were ignored. Non-ac- Openness and transparency vantages of the proposed treatment and commodative midwifery actions that The White Paper on Transforming the the patient’s decision to ask further had been poorly defined in terms of Public Service (1997) indicated that the questions; the benefits and the risks perceptions of conflicting expectations importance of the public service deliv- of all the procedures need to be dis- and unrealistic choices of the mother ery lies in the need to build confidence closed and explained, as well as all the were manifested. In midwife-centred and trust between the provider (mid- options that a mother might consider; care, the management of childbirth fo- wife) and the user (mother). Pera & midwives need to provide time, sup- cused on the detection of complica- port and encouragement to women in Van Tonder (1996:61) indicated that the tions. This did not always respect the labour to explore various options; the most satisfactory relationship between experience and expectations of child- written information should be plain and the nurse and the patient is character- birth and its outcome. Curationis September 2010 2002: Japanese Women’s experience decision-making in maternity care: re- Limitations of the study of childbirth in the United States. sults of a population-based survey. 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Midwives’ experiences of managing women in labour in the Limpopo Province of South Africa

Maputle, Sonto M.; Hiss, D. H.
Curationis – Jun 6, 2010
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0379-8577
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10.4102/curationis.v33i3.2
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Research Article Midwives’ experiences of managing women in labour in the Limpopo Province of South Africa SM Maputle, D.Cur Senior Lecturer, University of Venda: Department of Advanced Nursing Sience DC Hiss, PHD (Medicine) Professor, University Western Cape: Department of Medical Biosciences Key words Abstract: Curationis 33 (3): 5-14 Accommodative midwifery actions; Introduction: The objective of this study was to explore and describe the experiences maximisation of human and material in- of midwives managing women during labour at a tertiary care hospital in the Limpopo frastructure; collaboration; interde- Province. An exploratory, descriptive, contextual and inductive design was applied pendence and mutual participation. to this qualitative research study. Purposive sampling was used to select midwives who were working in the childbirth unit and had managed women during labour. A sample of 12 midwives participated in this study. Data were collected by means of unstructured individual interviews and analysed through an open coding method by the researchers and the independent co-coder. Findings: Categories identified were lack of mutual participation and responsibility sharing, dependency and lack of decision-making, lack of information-sharing, em- powering autonomy and informed choices opportunities, lack of open communica- tion and listening, non-accommodative midwifery actions, and lack of human and material infrastructure. To ensure the validity of the results, criteria to measure trustworthiness were utilized. Conclusions: This study has implications for woman-centered care by midwives managing women in labour and provides appropriate guidelines that should be inte- grated into the Batho-Pele Principles. Correspondence address Dr S. Maputle Private Bag X 5050 Thohoyandou Tel: (015) 962 8125 Fax: (015) 962 8647 E-mail: [email protected] Curationis September 2010 further separates the mind from the within this legal framework is that of Introduction body. The biomedical model and its Batho-Pele “People First”, implying that Midwives form the backbone of mater- dominant effect on healthcare have led the consumer of healthcare is placed at nal, child and women’s health in South to it being used in the interest of mid- the centre of healthcare delivery. It also Africa. Their caring for women during wives, for example, the model concen- means that healthcare delivery is trans- childbirth is a unique life event that is a trates information and decision-making formed in such a way that consumers core function of the midwifery profes- to doctors and midwives, and to a lesser are satisfied with it (Department of Pub- sion. Midwives play a vital role in the extent to women in labour. The mod- lic Service and Administration, 1997). implementation of the Batho Pele Prin- el’s emphasis is more on high technol- Sandall (1995:201) supports customer- ciples, Patients’ Rights Charter and ogy that inherently leads to the loss of oriented service delivery based on the Millennium Developmental Goals personalized and compassionate hu- philosophy that focus should shift from (MDGs). However, limited studies fo- man care. Women in labour are labelled technologisation to personalisation, cused on the experiences of midwives according to diagnosis rather than be- and thus to the creation of the para- managing women during labour. This ing known as patients with needs to be digm of a woman-centered practice study explored and described the ex- attended to. At the same time, Pearson based on equal partnership between periences of midwives who manage et al. (1998:37) affirm that the biomedi- women in labour and midwives. women in labour in a tertiary hospital cal model is well developed and un- in the Limpopo Province. doubtedly gives direction to midwifery Problem Statement practice, which is useful. The pressure When mothers are admitted to labour Background from society and increased understand- wards, midwives seem to focus mainly Childbirth, from the perspective of the ing of human rights through the Pa- on completing certain tasks before biomedical model (Pearson, Vaughan tients’ Charter and Batho-Pele Princi- handing over the report to the next mid- and Fitzgerald (1998:36), focuses on the ples have highlighted the restrictive wife on duty. Little effort is thus ex- physiological changes that take place nature of the biomedical model, the al- pended on meeting the needs of women during childbirth and the specialized ternative approach being the provision in labour as individuals. When man- scientific knowledge midwives possess of woman-centred care. The Batho- aging women in labour during child- with regard to these changes. The key Pele Principles seek to introduce a cus- birth, midwives follow a set of stand- focus of this model is on the manage- tomer-focused approach that aims to ards and procedures to monitor and ment of labour and the detection of put pressure on systems, procedures, regulate physiological developments. complications or normal childbirth. attitudes and behaviours within the Women in labour, too, are expected to The situation in hospitals that provide childbirth units and orient midwifery follow the set standards and midwifery childbirth care is such that prescribed practice towards the needs and advan- protocols. While these policies and routines are frequently adhered to as tages of customers, an approach which procedures might make sense from the laid down in the policies and proce- puts people first (Department of Public standpoint of midwifery care and pos- dures strategically placed in the ward. Service and Administration, 1997). The sibly also reflect the priorities dictated Midwives generally regard it as their White Paper further indicated that this by the biomedical model, they do not responsibility to ensure that this code does not necessarily mean introducing always manifest the experiences, needs of conduct is not breached. Pearson et more rules and centralised processes, and priorities of women in labour dur- al. (1998:34) indicate that the end re- or micro-managing service delivery ac- ing childbirth. Also, the experiences of sults of such an approach are stand- tivities. Rather, it involves creating a midwives facilitating active participa- ardised routines for maternal care dur- framework for delivery of public serv- tion and decision-making of women ing childbirth. They further point out ices which treats citizens more like cus- during childbirth are not well docu- that women in labour are often expected tomers and enables them to hold pub- mented. In view of this paucity, the to comply with a predictable pattern lic servants to account for the services present study sought to determine the and follow the routine laid down by the they render. Healthcare institutions midwives’ experiences of managing regulations. Such standardised rou- ought to create a people-centered and women who are in labour at a tertiary tines have some merit, but when fol- people-driven service that is character- hospital in the Limpopo Province. lowed without skilled assessment may ised by equity, quality, timeousness and pose a risk of depersonalising the a strong code of ethics (Revere & women in labour and discouraging any Black, 2003: 380). The White Paper on Research Question participation and involvement during Transforming Service Delivery (The The following research question midwifery care. This leads to the de- Department of Public Service and Ad- guided this study: What are the mid- valuation of acts related to how women ministration, 1997) through the eight wives’ experiences of managing women in labour experience their own child- Batho-Pele Principles (consultation, during labour at a tertiary hospital in birth, such as listening, comforting or service standard, courtesy, access, in- the Limpopo Province? offering choices. Thus, this model is formation, openness and transparency, not completely geared to meet the spe- redress and value for money) aims to Purpose Of The Study cific needs of women in labour. Pearson improve the entire standard of the pub- The purpose of the study was to ex- et al. (1998:36) view the biomedical lic service and the effectiveness of plore and describe the midwives’ expe- model as a reductionist and dualistic service delivery. Services should be riences of managing women during la- approach because it reduces the hu- based on a customer-orientated frame- bour in a tertiary hospital in the man body to a set of related parts and work. The guiding principle adopted Curationis September 2010 Limpopo Province. The findings of this Capricorn, Mopani, Vhembe, adequate only after sufficient data had study were used to develop the woman- Sekhukhune and Waterberg. As indi- been collected, saturation had occurred centered childbirth model (not de- cated in the Department of Health Re- and variation had been accounted for scribed here) and guidelines that are port (2005:52), the total population in and understood. Saturation means that integrated within the Batho-Pele Prin- the province is estimated at 5 514 mil- no new or relevant data seem to emerge ciples It is hoped that these guidelines lion of which females constitute 54%. for a particular category (Strauss & would assist midwives in the facilita- Of the total female population, 45% was Corbin, 1990:188). Twelve (12) mid- tion of mutual participation when man- in the childbearing age group. The wives had been sampled when satura- aging women during labour. health service structure in Limpopo tion was achieved. Province consists of 1 tertiary institu- tion, 6 district hospitals (level 2) and 36 Data collection Definitions Of Terms community hospitals (level 1). Of the Permission to gain entry into childbirth Concepts used in this study are defined 43 hospitals, 40 has functional mater- units was obtained following approval as follows: nity units for deliveries and an esti- from the Ethics Committee of the Uni- mated 64% of the total number of births versity of Johannesburg, the Provin- Experience occur in these hospitals. The tertiary cial Department of Health, and the hos- Experience is an event or circumstance hospital is a referral hospital for levels pital concerned. The project was ex- undergone or lived through (Oxford 1 and 2 hospitals within the province. plained to the unit managers and mid- English Dictionary, 2005). In this study, The current trend is that more women wives in the obstetrical wards. Written experience refers to all the circum- are giving birth in hospitals than at informed consent was obtained from stances that take place between the home in the Limpopo province (Depart- the midwives. A pilot study was con- midwife and the mother during child- ment of Health Report, 2005:52). ducted with 6 midwives to refine the birth. question (Burns & Grove, 2005:38). The aim was to see whether the question Research Methodology In labour was clear to the midwives. Midwives In this study, in labour refers to the proc- Procedure of research understood the question and the inter- ess when a woman gives birth to a child The research design was qualitative, views were conducted successfully. and the midwife managing her. The exploratory, descriptive and contextual The question and interview procedure process includes the first, second and (McLeod, 2001:54-56), and aimed to were not changed. These midwives third stages of labour. provide a description and an explora- were not included in the main sample. tion of a particular phenomenon or ex- Data were collected by means of un- Biomedical Model perience within the context of the phe- structured phenomenological in-depth Biomedical model refers to the model nomenon’s specific setting and world interviews (Burns & Grove, 2005:130). on which midwives base their practice. significance by using a The unstructured question directed at In this model, women in labour (pa- phenomenological approach. Phenom- the midwives was: “Could you please tients) are viewed as biological beings enology is a philosophy and method tell me about your experiences of man- and little attention is paid to the wider which stresses the importance of de- aging women who are in labour?” characteristics of their human nature scribing and understanding human ex- (Pearson, Vaughan & Fitzgerald, The interviews were conducted by the perience as it is lived, before theoris- 1998:27). In this study, the biomedical researcher in the labour ward’s rest ing it (Gu, Zhang & Ding, 2009). model refers to the midwife taking full room (quiet place), did not exceed 45 responsibility for controlling the child- minutes and were generally completed Population and sampling birth process without the mother’s par- within 24 hours of managing and con- The population consisted of all mid- ticipation and sharing responsibility. ducting a delivery. The interviews were wives who were managing women who conducted in English, tape-recorded were in labour in the obstetric unit of a Meta-theoretical and midwives assured that sensitive tertiary hospital in the Limpopo Prov- ethical issues such as maintaining con- Assumptions ince. Non-probability, convenience fidentiality of data and preserving the and purposive sampling were used in The meta-theoretical statements of the anonymity of the participants as well the study. The researchers conven- Batho-Pele Principles (Department of as using research for its intended pur- iently sampled the available midwives Public Service and Administration, poses will be strictly observed (Polit, who were providing midwifery care to 1997) were used as a frame of reference Beck & Hungler, 2001:73-89). women in labour during the active in this study, with emphasis on putting phase of labour (3 – 10 cm cervical dila- women in labour first with midwives Ethical considerations tation). Purposive sampling is a type facilitating mutual participation during The ethical standards as set by Demo- of non-probability sampling in which this process. cratic Nursing Organization of South data are collected from a group of par- Africa (DENOSA) were adhered to be- ticipants chosen for specific key char- Research Methodology fore and during the interview acteristic (Sells, 1997:172). All midwives (DENOSA, 1998:1-7). Privacy was en- Context who had at least two years experience The study was conducted in a tertiary sured during the interview. The par- in the obstetric unit and who had care hospital in the Limpopo Province ticipants were assured that their par- agreed to participate were sampled. In which consists of five districts, namely, ticipation was entirely voluntary and this study, the sample was considered Curationis September 2010 that they could withdraw from the re- Table 1: Categories that emerged from analysis of midwives’ search project at any stage if they felt experiences of managing women who are in labour like doing so. During the interview, communication skills, for example, prob- ing, were used to obtain the necessary Category Description information. Unstructured conversa- tions with midwives were held infor- 1. Limited mutual participation, responsibility-sharing, decision- mally throughout the labour phases. making and dependency These conversations were spontane- ous and emerged from natural social 2. Lack of information-sharing, empowering, autonomy and informed interaction, and contributed to the choices depth and richness of information that otherwise would have been difficult to 3. Limited open communication and listening capture through more structured inter- views. Field notes of events and con- 4. Non-accommodative midwifery actions versations that occurred when women in labour interacted with their midwives 5. Limited human and material infrastructure were recorded verbatim. Data analysis cal area; the researcher conducted the comfortable with their dependency on Data analysis is a process of bringing unstructured interviews until data satu- the midwives as they indicated that order to the data, organising what is ration occurred, that is, until the col- midwives were trained practitioners and collected into concepts, categories and lected data were repeated and confir- knew what is best for them. Since the basic descriptive statements (Marshall mation of previously collected data had women in labour depended on mid- & Rossman, 1999:111). Tape-record- taken place. Furthermore, categories wives, it was evident that they had lim- ings of the interviews were transcribed identified by the researcher were com- ited decision-making capability. Bluff verbatim in the language in which the pared with those pinpointed by the and Holloway (2008: 308) affirmed that interviews were held. The narrative other coder and no major discrepan- women often place themselves in the cies were observed. An in-depth lit- data from unstructured in-depth inter- hands of midwives and allow midwives erature review further confirmed these views were analysed qualitatively to make decisions for them, even if their categories. This enhanced through the open coding method to own wishes are neglected. confirmability. Transferability was en- develop categories (Tesch, 1990, cited sured by the researcher via data analy- in Cresswell, 2003:192). The independ- Fabian, Rádestad and Waldenstrõm sis, interpretation and in-depth discus- ent researcher was also requested to (2008: 230) further indicated that mid- sions in a research report. analyse the data according to the open wives are challenged to enforce equal coding method. The two analyses were opportunities to make information available and to encourage women in then compared to ensure trustworthi- Findings And labour to take responsibility for their ness. The selection of the analyser was Discussions own care. Gibbins and Thomson based on experience in qualitative re- Five categories emerged that described (2001:310) argued that being included search methodology. the experiences of midwives who are in and making decisions are reported managing women during labour at a as being crucial in helping women feel Trustworthiness tertiary hospital in the Limpopo Prov- in control during labour. According to The four criteria of trustworthiness, ince (Table 1). midwives interviewed, women in labour namely, credibility, dependability, trans- accepted (without questioning) deci- ferability and applicability, as outlined Category 1: Limited mutual sions made by the midwives. This in Lincoln and Guba (1985:301-318), stance placed the midwife in a position participation, responsibility- were used to establish the trustworthi- of power and authority to make deci- sharing, decision-making and ness of this study. In this study, cred- sions. However, in other instances the ibility was enhanced by the following dependency mother did not understand why certain considerations: the researcher had pro- Midwives were of the opinion that dur- decisions were made, but she still com- longed exposure to the field of study; ing labour women did not verbalise that plied because of the trust she put in the researcher is a midwife, who has they would like to participate in deci- the decision-maker, regardless of what knowledge and clinical experience in sion-making. Instead, women followed the decision entailed. Ritcher, Greaney, this area of expertise; the literature con- instructions of midwives. Lundgren McKeown and Cornell (2001:174) sup- sulted enabled the researcher to sat- and Dahlberg (2002:158) pointed out ported this contention by indicating isfy the criterion of being knowledge- that it is important for midwives to col- that participative decision-making re- able about the phenomenon under in- laborate with women in labour by in- quires patients be knowledgeable vestigation; the researcher bracketed viting them to participate and be re- about their healthcare. This means that existing knowledge and preconceived sponsible for their care during child- they should have the ability to proc- ideas, and especially personal views, birth. Midwives also indicated that ess medical information and under- about the existing problems in the clini- some of the women in labour were stand the outcomes of choices they Curationis September 2010 make. showing respect, and clarifying each Rádestad and Waldenstrõm (2008: 233). Providing midwifery care is potentially other’s expectations through the pro- Midwives have the capability of assist- stressful when women are not partici- vision of information on childbirth is- ing women in labour to contextualize pating in their care during childbirth. sues and available options. This sup- the information, by creating a relation- Midwives were of the opinion that port will facilitate an environment that ship of trust through respect. How- women in labour do not participate at is conducive to women becoming more ever, Pope, Graham & Patel (2001:238) all in their care and that they displayed involved and participating willingly in cautioned that there are some indica- limited responsibility-sharing and de- their midwifery care. In woman-cen- tions of stereotyped views. cision-making during childbirth. These tred care, the midwife should take the Midwife participants pronounced that sentiments were supported by one mid- following into consideration: kindness women in labour lacked accurate infor- wife, “The mother may not, however, and respect, listening care, a share in mation or knowledge about the under- be willing to participate in her care decision-making, and the opportunity standing and awareness of what should for various reasons. Some maybe un- for a woman to talk about her care. This happen during childbirth. During child- prepared for childbirth or maybe she approach would facilitate participation birth it was evident that women in la- had not discussed aspects of partici- during childbirth. bour with accurate and up-to-date in- pation during pregnancy.” Two other formation with regard to childbirth is- midwives indicated that “Women in sues and the available options were able Category 2: Lack of labour very easily put themselves into to make informed choices. The follow- information-sharing, the hands of the midwives. I don’t ing excerpt from the interviews exem- empowering, autonomy and know what the cause is or is it because plifies this statement, “When informa- informed choices there were no discussions regarding tion was shared with regard to child- Midwives expressed the opinion that responsibility during pregnancy? But birth issues and available childbirth women lack information regarding the at times there is an attitude in our so- options had been outlined, the women childbirth process. Gibbins and ciety that says a pregnant mother is ill in labour would be empowered.” One Thomson (2001:302) stated that there and must leave all the responsibility midwife participant who managed are many expressions of the need for to the midwives because they know women who lacked information said, information, reassurance and confi- best.” This was viewed by midwives “Most women who are in labour look dence-building. They further pointed as a ‘dependency syndrome’. Mid- confused and don’t listen to the in- out that information given during child- wives also felt that women were not structions carefully. They are anxious birth enables the mother to take deci- cooperating during labour. and don’t co-operate.” Another mid- sions and empowers her to make in- Midwives were also of the view that wife participant said, “Women in labour formed choices. In addition, Richter et their roles were to support the deci- seemed to be lacking information, al. (2001:174) asserted that if women sions of women during childbirth and some will even refuse to be done vagi- were not given adequate information, that the mother’s participation could be nal examination during labour. Primi- they might not be able to collaborate strengthened if a therapeutic environ- gravidae are worse because they close with their physicians or be willing or ment was created. One midwife partici- the thighs when the head crowns, but able to ask questions. Lack of shared pant exemplified this by describing how those with little information on what information was thus an obvious con- she supported the mother by explain- is going to happen, they are better, cern. Sharing of information in advance ing all procedures to her and promoted they do co-operate.” It was evident could build the necessary trust so that her participation by indicating that she from the transcripts of interviews with goals could be consciously adapted had to come up with her preferences midwives that limited information with throughout the childbirth process. Lim- for childbirth, and encouraged her to regard to childbirth issues, available ited information, ideas and options are ask questions. The following direct childbirth options and understanding often cited as reasons why women are quotations from the midwife support what should happen during childbirth socialised to accept pain as their lot in this notion: “Although women in la- contributed to limited capacity to make life (Mahmoud, 2006: 412). Gibbins and bour did not indicate their behaviour informed choices during childbirth by Thomson (2001:302) suggested that as preferences, they nevertheless par- the women. information given during childbirth ticipated by adopting a squatting po- enables the mother to take decisions sition during childbirth.” Another Category 3: Limited open and empowers her to make informed midwife participant said, “You know communication and listening. choices. This idea is supported by the some women are from a cultural envi- Communication between a midwife and concept that women need to be given ronment where the woman is not used a mother during childbirth should be information and the opportunity to dis- to expressing her wishes as this is not open and effective. Both parties should cuss how that information relates to allowed. For example, if the partner understand the language of the other. their particular circumstances. The is available during childbirth, when Midwife participants were of the opin- same concept is reinforced by the as- asked her wishes, she will look at the ion that women in labour are made to sumption that information builds con- partner and expect him to decide.” feel free to verbalise their thoughts and fidence and self-esteem which would Midwives could support and give wishes during childbirth. They further enable the mother to take control over women in labour the opportunity to indicated that they are being open, her childbirth, ask questions, make in- participate and be responsible during formed choices and communicate more supportive and that they listen to childbirth by being open, listening to women and understand their unique women, explaining all procedures, effectively with midwives (Fabian, Curationis September 2010 circumstances and their wishes. From (1991) in the study “Midwife/Client deemed that they promoted, supported the transcripts of interviews with mid- Relationship: Midwives’ Perspec- and respected the values, beliefs and wives, language barriers were cited as tives”, as cited in Doherty (2010:98). preferences of women as long as they a factor that interfered with their inter- The authors observed that women in were not harmful to the mother and action with women during childbirth. labour did not listen to midwives, and baby. They were also convinced that This was the case, especially with this led to a feeling of worthlessness. some women in labour had unrealistic women who were transferred from other The midwife just went through the choices, which could not be accommo- process of helping the mother, but no hospitals and who spoke a language dated by midwives. One midwife par- mutual trusting relationship was estab- different from that of the midwife. The ticipant said, “I accommodate women’ lished. hospital under study provided mid- preferences, for example, squatting, Takayama and Yamazaki (2003) recog- wifery care for all racial groups. Mid- but if I find difficulties in managing nised the need for effective patient- wives cited that women in labour the childbirth, I explain to the mother physician communication in childbirth. viewed them as being impatient; that the benefits of adopting the dorsal This is referred to as mutual participa- they did not listen; and seldom veri- position and guide her in adopting the tion and consultation. Lothian, fied why women in labour had specific position”. Fabian et al (2008: 232) sug- 2006:297outlined the potential benefits preferences. One midwife participant gested that women need to be given of a birth plan (woman-centred care) said that, some women who are in la- information and the opportunity to dis- with regard to communication as fol- bour are difficult and are unable to cuss how that information relates to lows: improved channels of communi- follow instructions, especially if they their particular circumstances before cation between the caregivers (mid- don’t understand the language.” In the stresses of labour make it unrealis- wives) and the consumers (women) and instances where the midwife spoke a tic to enter into detailed considerations creation of opportunities for discussion different language, physical presence of the pros and cons of childbirth. of preferences. To the researchers, and touch were found to be beneficial Some women preferred to have their these benefits would enhance effective as corroborated by one midwife par- partners present during labour, which communication during childbirth. A ticipant, “The midwife’s physical pres- is encouraged, however, midwives had birth plan that involves a midwife can ence helps to establish some contact variable preferences and views regard- give pregnant women information to with the mother if the midwife and ing the presence of a partner during make choices and help them feel more mother are not sharing the same lan- childbirth. One midwife responded, “I confident (Lothian, 2006:297; Berg, guage.” Communication is key during allow the presence and support of the 2005: 20). Effective communication will childbirth. Lack of effective communi- partner during delivery because if the then lead to openness and conveyance cation between a midwife and a mother companion is present during child- of safety. According to Lundgren and may lead to the midwife failing to give birth he will support by soothing and Berg, (2007:149); Lundgren and Berg a clear explanation about the childbirth massaging to the mother.” According (2005:226), a trusting relationship de- process. Language difficulties and lack to Lundgren and Dahlberg (2002:158), velops that mediates a feeling of of information and clarification on the the presence of the father interfered tranquility and security. The woman part of the midwife also contribute to with their contact relationship with the can relax and feel that she is participat- misunderstanding and mother. This view was echoed by one ing in decision-making and thus gain miscommunication (Ito & Sharts- midwife, “The presence of a compan- some measure of control of the situa- Hopko, 2002:673). In support of this ion/partner during childbirth is an tion. The emotional aspect of the view, Ito and Sharts-Hopko (2002:673) obstacle to good a relationship. It is mother thus becomes supported. Open argued that due to lack of English com- very difficult to establish contact with communication and listening leads to munication with caregivers, women feel the mother in the presence of the fa- a relationship of trust during midwifery that they do not have anything to do. ther who at times displays negative care. One midwife participant indicated He further indicated that women do not attitude, worry or is aggressive.” An- that she was firm and honest with understand the midwife and are there- other midwife corroborated this feeling, women during labour in order to build fore unable to ask any questions dur- “The presence of the partner interferes a relationship of trust, “I think it is ing childbirth. Limited listening skills with the mother’s decision, especially important for us midwives to make it lead to ineffective communication. The in cultures where husbands are the clear to women in labour, under our midwife should display openness, decision makers. In one incident, when care, for example, by indicating that which is a sign of willingness to listen, the mother was asked about her it is important for me that you have a observe and understand. In some in- wishes, she looked at the husband and good childbirth, I’m available for you, stances, women felt that some proce- asked him to decide. This made me I care for you, but you are not the only dures were imposed on them. This feel that I can’t do anything about patient for me, you are my patient right observation is in agreement with a re- that.” Several authors have spelt out now.”. Communication is critical to ef- port by Viisainen (2001) that the way clearly the advantages of the presence fective caring during childbirth. interventions and processes are intro- of a companion during childbirth duced are usually in an authoritative (Somers-Smith, 1999:105 cited in Category 4: Non- or non-listening manner, which contrib- Maputle & Nolte, 2008). However, in accommodative midwifery uted to women in labour feeling dis- most parts of the world, childbirth is actions turbed. On the other hand, midwives still regarded a predominantly female Pertaining to the issues of being ac- also showed concern for the mother as issue, and in the vast majority of tradi- commodative, midwife participants is discussed by McCrea and Crute tional cultures it is unbecoming of men Curationis September 2010 to be present at birth (Fabian et al, 2008: that the participants have virtually the in terms of which are relevant and eas- 235). Midwives raised different opin- same power, that they need one another, ily understood by women in labour ions with regard to physical comfort that the shared activity will be satis- (women should be able to judge for during childbirth. According to Bluff factory to both, and that both become themselves whether they are receiving & Holloway (2008: 308), women in la- active participants in the development what was promised). Service standards bour regard midwives as the practition- of the nursing care plan (Pera & Van should cover the women in labour’ main ers of normal midwifery because “they Tonder, 1996: 58). To realize the Bill of requirements, for example, access (lan- know best”. Rights, the Batho-Pele Principles, as a guage), courtesy (respect) and provi- Government initiative to put people sion of information (education). first, will be adapted in order to facili- Women in labour must know and un- Category 5: Limited human and tate mutual participation between derstand what quality of service they material infrastructure women in labour and attending mid- can expect to receive and what re- Midwives were not able to spend qual- wives during childbirth as follows: sources they have if the standard is ity time with the women during labour not met. The midwife should create to verify their preferences. A shortage opportunities to inform the mother Consultation of staff was cited in the interview tran- about the investigations, procedures Facilitation of consultation and scripts. It was pointed out that one and results of childbirth and explain participative decision-making are aimed midwife might be caring for more than (communication) the reasons where the at the establishment of the childbirth two women at the same time. Pelkonen, service has fallen short of what was education programme, which is a cli- Perala and Vehvilainen-Julknnen promised. ent-centred process that builds confi- (1998:22) have found that a busy and dence and self-esteem to enable women routine atmosphere inhibits participa- in labour to take responsibility and con- Access tion, whereas a friendly, peaceful and trol over their childbirth as active part- The ‘White Paper on Transforming secure environment provides opportu- ners. It provides a platform for them to Public Service Delivery (1997) states nities for participation. Tarkka, ask questions and seek information so that the service delivery programme Paunonen and Laippala (2000:188) cited that they can make informed choices should address the needs of all citizens in Maputle and Nolte, 2008) agreed that and communicate effectively with the to progressively redress the disadvan- in order for midwives to influence posi- attending midwives (Nolte, 1998: 116). tages of all barriers to access. During tive childbirth experiences, they should The goal of childbirth education pro- the provision of midwifery care, barri- display empathy, friendliness, tender- grammes is to provide women in labour ers to access should be taken into con- ness, calmness, alertness, peacefulness with useful information on childbirth sideration in order to facilitate mutual and professional expertise towards to acquire a sound knowledge to chal- participation as follows: The attitude women in labour. However, staff short- lenge the rationale of some of the pro- ages tend to jeopardize this positive of the midwife should be approachable; cedures they are expected to undergo. contribution and often lead to a feeling the midwife should respect, encourage The childbirth education programme is of tension in clinics and wards. and support the mother’s cultural and the movement that focuses its atten- personal preferences and choices; the tion on teaching women the medical style of language and choice of words Recommendations definitions surrounding birth and to used by the midwife should be care- The proposal was to create a paradigm prepare women in labour for hospital fully considered because words can of woman-centred care that is based experiences. When the mother plans reflect attitudes of respect or disrespect on equal partnership between the mid- to fall pregnant or when she is preg- inclusion or exclusion, judgment or ac- wives and the women who is in labour. nant, she needs to consult with a mid- ceptance, i.e., choice of words can ei- The woman-centered care would be wife who will encourage her to attend ther ease or impede communication; integrated in the Batho-Pele Principles. the childbirth education programme. and encouragement of decision-mak- Guidelines to enhance the facilitation The midwife ought to create opportu- ing, autonomy, informed choices and of mutual participation (interdepend- nities for the mother to become a part- personal control (except in situations ence) were formulated. Chapter 2 of ner. The techniques chosen for a par- of clear health risk). the Constitution of South Africa, ticular mother will be based on needs through the Bill of Rights, gives citi- assessment. During consultation, the Courtesy zens the right to take action against the midwife is expected to respect the Midwives have a powerful effect on state if they believe their constitutional women in labour’ past experiences, women who are giving birth. They rights had been infringed upon. It also plans and needs with regard to their should be aware that their power to in- states that they have the right to ac- childbirth options. fluence impacts both positively and cess information held by midwives negatively on the mother’s childbirth which they need in order to participate Service standard experience. Women in labour tend to in decision-making, exercise informed Service standards are commitments to remember the specific words and ac- choices, and enjoy the benefits of au- provide a specified level and quality of tonomy, empowerment and independ- tions of midwives and their satisfac- service to individual customers at any ence (The Constitution, 1996:15). In tion is linked to the type of care re- line with these Constitutional princi- given point in time (Department of Pub- ceived, feelings of personal control and ples, the facilitation of mutual partici- lic Service and Administration, 1997). accomplishment. Midwives are ex- pation is based on the assumptions Service standards should be expressed pected to treat all women with cour- Curationis September 2010 tesy, respect and dignity during child- free of jargon -it should be supported ized by mutual trust. They further birth. When women in labour are by visual aids and other graphical ma- pointed out that trust forms the basis treated with courtesy and respect dur- terial (e.g., slides, films and videos) to of a successful and effective healthcare ing childbirth, they participate actively clarify the verbal information and to relationship. in their care. The following actions facilitate understanding ,however, cul- could be implemented to ensure that tural relevance should also be consid- Conclusion courtesy is taken into consideration: ered; handouts on specific topics could From the results of the interviews, it the Unit Managers should ensure that be supplied as a method of informing would appear that the tertiary hospital the values and behavioural norms of women during childbirth; information in the Limpopo Province has midwife- the units are in line with the Principles about the available services should be centred care rather than woman-cen- of Batho-Pele; the performance of mid- communicated to women in labour; tred care during childbirth. In midwife- wives who are in contact with women when all relevant information has been centred care, the midwife tells the during labour must be regularly moni- made available to the mother for the women what to do and how to behave. tored and recorded; opportunities achievement of her goals, she should The approach during childbirth was should be provided to midwives to sug- be guided and not directed by the mid- characterized by limited mutual partici- gest ways of improving midwifery care; wife to share the responsibility for her pation and responsibility-sharing. This the training programme that includes care during childbirth; information comprised of inadequate participation, day-to-day guidance should be devel- shared between the mother and the limited decision-making scope, a pro- oped in order to ensure that Batho-Pele midwife is valued by women in labour. liferation of practices that fostered de- Principles are implemented in the child- Maputle and Nolte (2008: 60) indicated pendency, and a prevailing authorita- birth unit; and it is proposed that the that women viewed attending of classes tive approach within the childbirth unit. midwife who renders care to the mother as a type of insurance because it ena- The strict routines that were laid down on admission in the hospital be the one bles them to feel more secure and in- by the regulations seemed to deperson- who delivers the mother in order to formed. The content of childbirth edu- alise the mother, thus resulting in her strengthen the relationship of trust. cation programmes should be adapted non-participation. Midwives imposed to the needs of the mother and could their authority and responsibility to cover the following: anatomical, physi- Information ensure that the rules were adhered to. ological, psychological and emotional Sharing information is a mutual respon- changes during pregnancy, labour and sibility of the midwife and the mother. pueperium, including changes that Women who are in labour were seen The consultation process should be could affect the partner; prevention merely as the ones who should comply used establish what women in labour and early detection of complications of with the rules of the unit while having need to know and where and when the childbirth; and management and care no decision-making power. There was information can be best provided. This of minor illnesses encountered during also an over-reliance on technology. could be achieved through the follow- pregnancy, labour and pueperium; pain Limited information-sharing and em- ing actions: the midwives should pro- relief during labour; orientation with powering were displayed in this ap- vide accurate and up-to-date informa- regard to the physical surroundings of proach. Information regarding child- tion about the childbirth process, ex- the labour ward, different techniques birth issues and awareness of available plain it fully by presenting the pros and used in hospital, basic routines of the options was not shared with the women cons about the care they would pro- hospital and all other aspects of preg- in labour. This resulted in a feeling of vide; when providing information, in- nancy, labour and pueperium (adapted powerlessness and a lack of autonomy dividual or group teaching methods from Nolte, 1998:120). However, Fabian should be adopted; relevant informa- in childbirth care. Hindered or ineffec- et al (2008: 234) is of the opinion that it tion should be provided in the womens’ tive communication, such as, inad- is very unlikely that the childbirth edu- own language (access) in order to meet equate listening skills of attending mid- cation programme, as it is currently of- the needs of the mother; the informa- wives and the existence of a language fered, is making a significant contribu- tion should be made simple in order to barrier between women and midwives tion towards putting most women at maximize its comprehension and pre- often resulted in limited participation the centre of their own care and ena- vent any potential imposition of the by the women in labour. The midwife- bling them to participate in decision- attending midwife’s view; when pre- centred care approach was confined to making about the management of their senting information to women in labour, the physiological processes of child- childbirth. an interval should elapse between the birth while the psychosocial aspects presentation of advantages and disad- of the mother were ignored. Non-ac- Openness and transparency vantages of the proposed treatment and commodative midwifery actions that The White Paper on Transforming the the patient’s decision to ask further had been poorly defined in terms of Public Service (1997) indicated that the questions; the benefits and the risks perceptions of conflicting expectations importance of the public service deliv- of all the procedures need to be dis- and unrealistic choices of the mother ery lies in the need to build confidence closed and explained, as well as all the were manifested. In midwife-centred and trust between the provider (mid- options that a mother might consider; care, the management of childbirth fo- wife) and the user (mother). Pera & midwives need to provide time, sup- cused on the detection of complica- port and encouragement to women in Van Tonder (1996:61) indicated that the tions. This did not always respect the labour to explore various options; the most satisfactory relationship between experience and expectations of child- written information should be plain and the nurse and the patient is character- birth and its outcome. Curationis September 2010 2002: Japanese Women’s experience decision-making in maternity care: re- Limitations of the study of childbirth in the United States. sults of a population-based survey. 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