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Mothers’ experiences of labour in a tertiary care hospital

Mothers’ experiences of labour in a tertiary care hospital RESEARCH Dr MS Maputle Ph D Ph D student, Department of Nursing, Faculty of Health Sciences, University of Johannesburg Prof A Nolte Ph D Professor, Department of Nursing, Faculty of Health Sciences, University of Johannesburg Corresponding author: [email protected] Keywords: experience of labour; accommodative midwifery actions; maximise human and material infrastructure; midwife; South Africa ABSTRACT The purpose of the study was to explore and describe experiences of mothers during childbirth in a tertiary hospital in the Limpopo Province. This was achieved through a qualitative research study which was exploratory, descriptive, contextual and inductive in nature. A sample of 24 mothers participated in this study. Data obtained from unstructured in-depth interviews were analysed according to the protocol by Tesch (1990, cited in Cresswell, 1994:155). Five themes were identified, namely mutual participation and responsibility sharing, dependency and decision-making; information sharing and empowering autonomy and informed choices; open communication and listening; accommodative/non-accommodative midwifery actions; and maximising human and material infrastructure. The themes indicated experiences that foster or promote dependency on midwifery care. Guidelines on how to transform this dependency into a mother-centered care approach during childbirth are provided. OPSOMMING Die doel van die studie was om moeders se belewenis van kindergeboorte in ’n tersiêre hospitaal in die Limpopo Provinsie te verken en te beskryf. Dit is gedoen deur middel van kwalitatiewe navorsing wat verkennend, beskrywend, en kontekstueel was. ‘n Steekproef van 24 moeders het aan die studie deelgeneem. Inligting is verkry deur middel van ongestruktureerde in-diepte onderhoude. Hierdie inligting is geanaliseer aan die hand van Tesch (1990: aangehaal in Creswell, 1994:155) se protokol. Die volgende kategorieë is geïdentifiseer, wedersydse deelname en gedeelde verantwoordelikhede, afhanklikheid en besluitneming, deel van inligting, bemagtiging tot outonomie en ingeligte keuse, oop kommunikasie en luister, akkommoderende/nie-akkommoderende vroedvrou-aksies en bevordering van menslike en materiële infrastrukture. Die resultate van die onderhoude het belewenisse blootgelê wat dui op die bevordering van afhanklikheid in vroedvrouversorging. Riglyne om hierdie afhanklikheid te verander in ‘n moedergesentreerde benadering word verskaf. HEALTH SA GESONDHEID Vol.13 No.1 - 2008 55 INTRODUCTION It was further indicated that this does not necessarily mean introducing more rules and centralised processes, The Limpopo Province consists of six districts, namely; or micro-managing service delivery activities. Rather, it Capricorn, Mopani, Bohlabela, Vhembe, Sekhukhune involves creating a framework for delivery of public and Waterberg. Each is further divided into sub-districts services which treats citizens more like customers and and municipalities. As indicated in the Department of enables them to hold public servants to account for the Health Reports (2002:52), the total population in the services they render. province is 5.514 million of which 54% were females. Of the total female population, 45% were in the The White Paper on Transforming Service Delivery childbearing age group. The health service structure (Department of Public Service and Administration: 1997) consisted of one (1) tertiary institution, six (6) districts through the eight Batho-Pele Principles (consultation, hospitals (level 2) and thirty-six (36) community service standard, courtesy, access, information, hospitals (level 1). The tertiary hospital is a referral openness and transparency, redress and value for hospital for levels 1 and 2 hospitals within the Province. money) aim at improving the entire standard of the public In the Limpopo Province more mothers currently give service and effective service delivery. Services should birth in hospitals than at home. According to the be based on a customer-orientated framework. Department of Health Report (2002:52), the Province had a total of 43 hospitals, of which 40 had functioning Sandall (1995:201) is in support of customer-oriented maternity units for deliveries and an estimated 64% of service delivery when he points out that the philosophy births occurred in the hospitals. and focus should shift from technologisation to personalisation, and to creation of the paradigm of a When mothers enter the hospital to give birth they are woman-centered practice based on equal partnership usually unfamiliar with both the surroundings and the between mothers and attending midwives. structure of the ward and they are not well acquainted with the rules that govern behaviour in the obstetric unit PROBLEM STATEMENT setting. The policies and procedures are strategically placed in the ward and midwives seem to regard it as The challenges posed by the utilisation of the biomedical their responsibility to ensure that the rules are adhered model are that attending midwives tend to continue to to. Such standardised routines do have some merit, view mothers as physical beings and pay little attention but when followed without skilled assessment they may to the broader characteristics of human nature. Mothers pose the risk of depersonalising the mothers and seem to have limited powers compared to their discouraging any participation and involvement during attending midwives who focus mainly on completing midwifery care (Pearson, Vaughan & Fitzgerald, certain tasks before handing over the report to the next 1998:34). The care becomes midwife-centered and not midwife on duty. Thus little effort is expended on meeting patient-centered. It might become more important for the needs of mothers as individuals. the midwives to meet their own needs and solve their own problems instead of that of the woman in labour. Once mothers seek midwifery care during childbirth, they are expected to follow set standards and midwifery The pressure from society and increased understanding protocols, because the midwives follow set standards of human rights through the Patients’ Charter and Batho- of procedures to monitor and regulate physiological Pele Principles have highlighted the restrictive nature developments. While these policies and procedures of the biomedical model, the alternative approach being might make sense from the standpoint of midwifery care the provision of woman-centered care. The Batho-Pele and possibly also reflect the priorities dictated by the Principles seek to introduce a customer-focused biomedical model, they do not always manifest the approach that aims at putting pressure on systems, experiences, needs and priorities of mothers during procedures, attitudes and behaviour within the childbirth childbirth. It is therefore important to determine how units and re-orienting the attending midwives in the mothers experience the care that they receive during customers’ favour, an approach which puts people first (Department of Public Service and Administration, 1997). 56 HEALTH SA GESONDHEID Vol.13 No.1 - 2008 childbirth. A qualitative design was chosen for this project, as the focus was on exploring and describing the experiences PURPOSE OF THE STUDY of childbirth by mothers. The research thus aims to provide a description and an exploration of a particular The aim of this study was to explore and describe phenomenon or experience, within the context of the experiences of mothers during childbirth in a tertiary phenomenon’s specific setting and world significance hospital in the Limpopo Province. This would be done by using a phenomenological research method. as a first step towards eventually developing a mother- centered childbirth model that would be utilised to assist Population and sampling the attending midwives in the facilitation of mutual participation when managing mothers during childbirth The population consisted of all mothers who had been (The model will not be discussed in this article). admitted to deliver their babies in the obstetric unit of a tertiary hospital in the Capricorn district, Limpopo DEFINITIONS OF TERMS Province. Non-probability, convenience sampling was used in the study. Concepts used in this study are defined as follows: Mothers were selected from the obstetric unit of one Experience hospital in the Capricorn district in the Limpopo Province. This hospital was used as it is an obstetrical Experience is an event or circumstances undergone or referral hospital for all six districts in the Limpopo lived through (Oxford English Dictionary, 1999). It is Province. The researcher selected available mothers in directly related to a person’s internalisation of an event, the first stage of labour who meet the inclusion criteria. which he/she has personally lived through. In this study The mothers who were selected were interviewed in experiences include emotions, thoughts, preferences, the post-natal ward within 24 hours after delivery. The perceptions and values. interviews were held in the post-natal ward to enable mothers to describe their experiences of all three stages Childbirth of labour. In this study childbirth refers to the process when a The criteria for inclusion were mothers: mother gives birth to a child, and includes the first, • with a term pregnancy; second and third stages of labour. It includes all vaginal • in early active labour, who went through the first, births. second and third stages of labour in the hospital; • with the presence of a fetal heart rate; and Biomedical Model • that should have been able to understand and speak English. Biomedical model refers to the model on which nurses base their practice and view patients as biological beings In this research the adequacy of the sample was and pay little attention to the wider characteristics of attained when sufficient data had been collected so human nature (Pearson, Vaughan & Fitzgerald, that saturation occurs and variation is both accounted 1998:27). It refers in this study to the midwife taking for and understood. According to Glaser and Strauss full responsibility for controlling the childbirth process (in Strauss and Corbin, 1990:188) saturation means without the mother participating and sharing that no new or relevant data seem to emerge regarding responsibility. a category, the category development is dense and the relationship between the categories are well RESEARCH METHODOLOGY established. Twenty-four mothers were sampled when saturation was achieved. Research design and methods of data collection Data collection HEALTH SA GESONDHEID Vol.13 No.1 - 2008 57 Permission to gain entry into childbirth units was well, so no changes were made to the question and obtained following approval from the Ethics Committee interview procedure. This patient and interview were of the Rand Afrikaans University, the Provincial therefore added to the main sample. Department of Health, and the hospital concerned. The project was explained to the unit managers, attending Data analysis midwives and mothers of the obstetrical and postnatal wards. Written informed consent was obtained from Tape recordings of the interviews were transcribed mothers. verbatim in the language in which the interviews were held. The narrative data from unstructured in-depth Unstructured in-depth interviews were conducted in interviews were analysed qualitatively through the open English with the mothers. The question directed at the coding method (Tesch, 1990, cited in Creswell, mothers was: “Could you please tell me about your 1994:155). Data analysis is a process of bringing order experiences of childbirth in this hospital?” to the data and organising what is collected into concepts, categories and basic descriptive statements The researcher contacted each participant in the post- (Patton 1987:144). natal ward to confirm an appointment for the interview at a quite place in the post-natal ward and at an Another person was requested to also analyse the data appropriate time for the participants. The interviews were according to Tesch’s method (Tesch, 1990, in Creswell, tape-recorded and comments were made about 1994:155), independently from the researcher. The two sensitive ethical issues such as maintaining analyses were then compared to ensure confidentiality of data and preserving the anonymity of trustworthiness. The other analyser was selected as the informants and using research for its intended she had experience in qualitative research methodology. purposes (Creswell, 1994:148). The tapes were numbered and the participants’ names were nowhere TRUSTWORTHINESS mentioned. The ethical standards as set by DENOSA (Democratic Nursing Organisation of South Africa) were The four criteria of trustworthiness, namely, credibility, adhered to before and during the interview (DENOSA, dependability, transferability and applicability, as 1998:1-7). outlined in Lincoln and Guba (1985:301-318) were used to establish the trustworthiness of this study. The researcher created a context that was conducive to mutual trust between researcher and participant. To enhance credibility the researcher: Other ethical issues that were considered were the • had prolonged contact with the study field. She following: Privacy was ensured during the interview. The was a midwife, who had knowledge and clinical participants were ensured that their participation is experience in this area. The literature that was entirely voluntarily and that they could withdraw from consulted enabled her further to satisfy the criterion the research at any stage if they feel so. The interviews of being knowledgeable about the phenomenon would be stopped if the participant suffered severe stress under investigation; during the interview. The possibility of referring the • bracketed existing knowledge and preconceived patients for counselling was discussed with the patients ideas and especially personal views about the after the interview. During the interview communication existing problems in the clinical area; and skills for example probing was used to obtain the • conducted the unstructured interviews until data necessary information. saturation occurred, namely until the collected data were repeated and confirmation of previously A pilot study was conducted with one mother to refine collected data took place. the question. The question was asked to one mother and the interview was conducted as planned. The reason The categories identified by the researcher were was to see whether the question was clear to the mother compared with those identified by the other coder. No and whether the interview developed as planned. The major discrepancies were identified between these mother understood the question and the interview went persons’ analysis of the data. An in-depth literature 58 HEALTH SA GESONDHEID Vol.13 No.1 - 2008 review further confirmed these categories. This I can participate.” “They know what to do and how to enhanced confirmability. care for us during labour but at times I just felt I’m not involved because I’m just told what to do without being Transferability was ensured by the researcher providing asked. I don’t want to be restricted”. in-depth discussions of the data obtained, data analysis and interpretation of the research findings in a research According to Berg, Lundgren, Hermansson, and report. Wattberg (1996:15) mothers are said to have had negative experiences when they lose control of the ETHICAL CONSIDERATIONS situation and are not able to participate in the decision- making. They further indicate that this occur in Ethical considerations were based on the DENOSA situations where midwives take control without giving Ethical Standards for Nurse Researchers (1998:2.3.2- the mother the necessary time to be involved. Lundgren 2.3.4). The different ethical issues were referred to under and Dahlberg (2002:158) point out that it is important data gathering. for midwives to collaborate by inviting the mothers to participate and be responsible for their care during FINDINGS AND DISCUSSIONS childbirth. The results from the experiences of the mothers during Some of the mothers, on the other hand, were childbirth revealed five (5) themes, with their sub- comfortable with their dependency on the midwives as categories. The themes are not given names, but are they indicated that midwives are trained practitioners referred to as theme 1, for example. The categories and they know best. The mothers mentioned that they under the themes were then given descriptive names. did not have anything to say, but to listen to the See Table 1: midwives. The following quotes were cited by mothers: “During childbirth I was following all the instructions as Theme 1: Mutual participation, was instructed by the sister because the sister has responsibility sharing, dependency and knowledge and I’m ill”. “No, during childbirth I don’t have decision-making anything to say, but I must listen to all what midwives says”. The transcripts of the mothers indicated that there was limited participation and collaboration between them Since the mothers depended on the midwives, it was and the midwives during childbirth. The mothers were evident that they had limited decision-making capability. of the opinion that the midwives did not involve them One mother participant indicated that she was willing when providing midwifery care as they just instructed to take part in the decision-making, but lacked factual them on what to do and also pointed out that the or accurate information with regard to the available midwives were not friendly. The following quotes from options, as the following quote indicates: “I would be the mothers’ interviews support this feeling: “I was not very happy to be involved in decision-making during involved and not informed about my progress, the childbirth, but this was not the case and we need to be midwives will examine me and I will only overhear them given more information on all issues relating to childbirth giving each other the report, but not telling me so that because if we are having information we can decide Table 1: Themes and sub-categories THEMES 1. 2. 3. 4. 5. Mutual participation Information sharing Open Accommodative/No Maximize human SUB- and responsibility and empowering communication and n-accommodative and material CATE sharing, autonomy and listening midwifery actions infrastructure GORIES dependency and informed choices decision-making HEALTH SA GESONDHEID Vol.13 No.1 - 2008 59 From the interview transcripts of mothers, language and make informed choices”. barriers were cited as a factor that interfered with their interaction during childbirth (especially to mothers who Bluff and Holloway (1994:160) point out that women were transferred from other hospitals and who used place themselves in the hands of midwives and allow different languages from that of the attending midwife) midwives to make decisions for them even if their own because the tertiary hospital provides midwifery care wishes are neglected. Nolan (1997:1201) further to all racial groups. Some of the mother participants indicates that midwives are challenged to enforce equal revealed that midwives were impatient, did not listen to opportunities of making information available and to them and seldom verified why they had specific encourage mothers to take responsibility for their own preferences. The mother participants felt that the care. Gibbins and Thomson (2001:310) indicate that attending midwives lacked listening skills which being included in and making decisions are reported hindered verbal communication during childbirth as the as being crucial in helping mothers feel in control during following remarks made by the interviewees revealed: childbirth. “Some midwives must be patient and at least listen to what I want to say, they have knowledge and I know Theme 2: Information sharing, that they are busy but even if you ask a small thing empowering, autonomy and informed they won’t listen. For example, if you indicate the choices preference they don’t allow or even listen to why you make such a preference” and “Hmm … I didn’t clearly When information is shared with regard to childbirth understand the language of the midwife, but I would issues and available childbirth options outlined, mothers like to be assisted especially if there are complications”. would be empowered. The mothers emphasised that they were lacking factual information on childbirth Theme 4: Accommodative midwifery issues and on available birth options or choices. They actions also did not have a good understanding of the available options which they could exercise as the right to choose Nolan (1997:1201) suggests that women need to be during childbirth. The following excerpt from some of given information and the opportunity to discuss how the mothers’ interviews was cited with regard to available that information relates to their particular circumstances options and childbirth issues: “(Laughing …) I don’t before the stresses of labour make it unrealistic to enter know what to expect and what is going to happen during into detailed considerations of the pros and cons of childbirth, the midwives and doctors know exactly, they childbirth. Contrary to this, the mothers indicated to are able even to determine the complications early and the midwives that they wanted to be respected and to prevent them”. treated as adults. “I expected good care from the midwives. They must treat me as a person, listen to A lack of shared information was thus seen as an me and empathize with me as I was feeling pain” and obvious concern. Halliday and Hogart-Scott (2000:63) “During childbirth there should be communication as well as Gibbins and Thomson (2001:302) state that between the midwife and myself, they must listen and there are many expressions of the need for information, clearly explain to me if what I prefer is not possible”. reassurance and confidence building. They further point out that information given during childbirth enables the The mothers indicated that they would prefer the mother to take decisions and empowers her to make presence of a companion, but were not informed that informed choices. In addition, Richter, Greaney, this was possible as the following expression indicate: McKeown, Cornell, Littleton and Pulley. (2001:174) point “If I knew that my partner could be allowed in, I would out that if women are not given adequate information, have loved that so that he can witness how the baby is they may not be able to collaborate with their physicians delivered and I think this will strengthen the bond or be willing or able to ask questions. between the two of us” and “My partner should be present, he must see how pain is, and he must be Theme 3: Open communication and involved and understand how painful childbirth is … listening 60 HEALTH SA GESONDHEID Vol.13 No.1 - 2008 and he will agree if I opt for sterilisation”. unit. The strict routines that are laid down by the regulations seem to depersonalise the mother, re- Several authors have spelt out clearly the advantages sulting in her non-participation. Midwives impose of the presence of a companion during childbirth their authority and responsibility to ensure that the (Micklethwait, Beard & Shaw, 1978:190; Somers-Smith, rules are adhered to. Mothers are merely seen as 1999:105). However, Nolan (1997:1198) points out that the ones who should comply with the rules of the in most parts of the world childbirth is a female issue unit while having no power of decision, and there is and in the vast majority of traditional cultures it is an over-reliance on technology. unheard of for men to be present at birth. • Limited information sharing and empowering is displayed in this approach, that is, information Theme 5: Maximise human and material regarding childbirth issues and awareness of infrastructure available options are not shared with the mothers which result in powerlessness and a lack of A shortage of staff was cited in the interview transcripts. autonomy in childbirth care, this therefore also limits It was pointed out that one midwife would be caring for their ability to take independent decisions. more than two mothers at the same time. Midwives • Hindered/ineffective communication, for example, were not able to spend quality time with the mothers inadequate listening skills of attending midwives and to verify their preferences. Pelkonen, Perala and and the existence of a language barrier between Vehvilainen-Julknnen (1998:22) state that a busy and mothers and midwives often result in limited routinised atmosphere has been found to inhibit participation by the mothers. The midwife-centered participation, whereas a friendly, peaceful and secure care approach seems to limit itself to the situation provides opportunities for participation. Staff physiological processes and the psychosocial shortages do contribute to a feeling of tension in clinics aspects of the mother are thus ignored. and on the wards (Micklethwait et al. 1978:190). • Non-accommodative midwifery actions with regard to poorly defined perceptions of conflicting Almost all the mothers agreed that they valued the expectations and unrealistic choices of the mother presence of a midwife who gave detailed information on were manifested. In midwife-centered care, the what to expect and about the progress of the labour. management of childbirth is focused on the Tarkka, Paunonen and Laippala (2000:188) support this detection of complications, which does not always by stating that for the attending midwives to influence respect the experience and expectations of the mothers’ positive childbirth experiences; they should childbirth and its outcome. display empathy, friendliness, tenderness, calmness, alertness, peacefulness and professional expertise. LIMITATIONS OF THE STUDY CONCLUSION There are no limitations of the study except possible bias of the persons who did the analysis and The results of the interviews seemed to have revealed interpretations of the data. midwife-centered care rather than mother-centered care during childbirth in the unit of the tertiary hospital in the RECOMMENDATIONS Capricorn district of the Limpopo Province. In midwife- centered care, it is the midwife who tells mothers what The recommendation is thus to create a model of to do and how to behave. This approach during childbirth mother-centered care that is based on equal partnership is characterised by: between the mothers and attending midwives. The procedures to obtain the mother-centered care should • Limited mutual participation and responsibility be described in detail in this model. sharing, which comprise of inadequate participation, The mother-centered care approach during childbirth, limited decision-making scope and a proliferation described in this model should be characterised by: of practices that foster dependency, and a • Participation that requires a mutual, egalitarian and prevailing authoritative approach within the childbirth respectful relationship. Equality includes the HEALTH SA GESONDHEID Vol.13 No.1 - 2008 61 principle of sharing power and responsibility. There Journal, 2:188-191. should be leverage for negotiation between the NOLAN, ML 1997: Antenatal education - Where next? Journal of mother and the midwife. Advanced Nursing, 25(6):1198-1204. • Sufficient information provided by the attending OXFORD ENGLISH DICTIONARY 1999: University Press. midwives and which is a prerequisite for decision- PATTON, F 1987: Qualitative evaluation and research methods. making. Newbury Park: Sage. • Interaction between the mother and the midwife PEARSON, A; VAUGHAN, B & FITZGERALD, M 1998: Nursing should enhance the self-esteem and self- models for practice. Melbourne, Johannesburg: Butterworth- determination of the mother. The midwife and the Heinemann. mother should listen to each other because they PELKONEN, M; PERALA, ML & VEHVILAINEN-JULKNNEN, K 1998: engage in a dialogue to identify preferences and Participation of expectant mothers in decision-making in maternity expectations so that a new strategy for change is care: results of a population-based survey. Journal of Advanced constructed. Nursing, 28(1):21-29. • In this study the new strategy for change will be to RICHTER, DL; GREANEY, ML; McKEOWN, RE; CORNELL, CE; develop a woman-centered childbirth model and to LITTLETON, MA & PULLEY, L 2001: Developing a video intervention formulate criteria that would be integrated within to model effective patient-physician communication and health- the Batho-Pele Principles aimed at enhancing the related decision-making skills for a multi-ethnic audience. JAMWA, facilitation of mutual participation during childbirth. 56(4):174-176. SANDALL, J 1995: Choice, continuity and control: Changing REFERENCES midwifery towards a social perspective. Midwifery, 11(4):201- BERG, M; LUNDGREN, I; HERMANSSON, E & WAHLBERG, V 1996: SOMERS-SMITH, MJ 1999: A place for the partner? Expectations Women’s experiences of the encounter with the midwife during and experiences of support during childbirth. Midwifery, childbirth. Midwifery, 12(1):11-15. 15(2):101-108. BLUFF, R & HOLLOWAY, I 1994: They know best: Women’s per- SOUTH AFRICA: DEPARTMENT OF PUBLIC SERVICE AND ceptions of midwifery care during labour and childbirth, Mid- ADMINISTRATION 1997: People First: White paper on Transforming wifery, 10(3):157-164. Public Service delivery. Pretoria: Government Printers. CRESSWELL, JW 1994: Research design: Qualitative and STRAUSS, A & CORBIN, J 1990: Basics of qualitative research: quantitative approaches. Thousand Oaks: Sage. Grounded theory procedures and techniques. Newbury Park: DEMOCRATIC NURSES ORGANISATION OF SOUTH AFRICA Sage. (DENOSA) 1998: Ethical standards for the nurse researcher. TARKKA, MT; PAINONEN, M & LAIPPALA, P 2000: Importance of Pretoria: DENOSA. the midwife in the first time mother’s experience of childbirth. DEPARTMENT OF HEALTH 2002: Saving babies: Third perinatal Scandanavian Journal Caring Science, 14(3):184-190. care survey of South Africa. Pretoria: Government Printers. DEPARTMENT OF PUBLIC SERVICES AND ADMINISTRATION 1997: People first: White Paper on Transforming Public Service Delivery. Pretoria: Government Printers. GIBBINS J & THOMSON AM 2001: Women’s expectations and experiences of childbirth. Midwifery, 17(4):302-313. HALLIDAY, SV & HOGARTH-SCOTT, S 2000: New customer to be managed: Pregnant women’s views as customers of health care. Journal of Applied Management Studies, 9(1):55-68. LINCOLN, M & GUBA, EG 1985: Criteria for assessing trustworthiness of naturalistic inquiry. Thousand Oaks: Sage. LUNDGREN, I & DAHLBERG, K 2002: Midwives’ experience of the encounter with women and their pain during childbirth. Midwifery, 18(2):155-164. MICKLETHWAIT, L; BEARD, R & SHAW, K 1978: Expectations of the pregnant woman in relation to her treatment. British Medical 62 HEALTH SA GESONDHEID Vol.13 No.1 - 2008 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health SA Gesondheid Unpaywall

Mothers’ experiences of labour in a tertiary care hospital

Maputle, M S; Nolte, A
Health SA Gesondheid – Nov 12, 2008
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RESEARCH Dr MS Maputle Ph D Ph D student, Department of Nursing, Faculty of Health Sciences, University of Johannesburg Prof A Nolte Ph D Professor, Department of Nursing, Faculty of Health Sciences, University of Johannesburg Corresponding author: [email protected] Keywords: experience of labour; accommodative midwifery actions; maximise human and material infrastructure; midwife; South Africa ABSTRACT The purpose of the study was to explore and describe experiences of mothers during childbirth in a tertiary hospital in the Limpopo Province. This was achieved through a qualitative research study which was exploratory, descriptive, contextual and inductive in nature. A sample of 24 mothers participated in this study. Data obtained from unstructured in-depth interviews were analysed according to the protocol by Tesch (1990, cited in Cresswell, 1994:155). Five themes were identified, namely mutual participation and responsibility sharing, dependency and decision-making; information sharing and empowering autonomy and informed choices; open communication and listening; accommodative/non-accommodative midwifery actions; and maximising human and material infrastructure. The themes indicated experiences that foster or promote dependency on midwifery care. Guidelines on how to transform this dependency into a mother-centered care approach during childbirth are provided. OPSOMMING Die doel van die studie was om moeders se belewenis van kindergeboorte in ’n tersiêre hospitaal in die Limpopo Provinsie te verken en te beskryf. Dit is gedoen deur middel van kwalitatiewe navorsing wat verkennend, beskrywend, en kontekstueel was. ‘n Steekproef van 24 moeders het aan die studie deelgeneem. Inligting is verkry deur middel van ongestruktureerde in-diepte onderhoude. Hierdie inligting is geanaliseer aan die hand van Tesch (1990: aangehaal in Creswell, 1994:155) se protokol. Die volgende kategorieë is geïdentifiseer, wedersydse deelname en gedeelde verantwoordelikhede, afhanklikheid en besluitneming, deel van inligting, bemagtiging tot outonomie en ingeligte keuse, oop kommunikasie en luister, akkommoderende/nie-akkommoderende vroedvrou-aksies en bevordering van menslike en materiële infrastrukture. Die resultate van die onderhoude het belewenisse blootgelê wat dui op die bevordering van afhanklikheid in vroedvrouversorging. Riglyne om hierdie afhanklikheid te verander in ‘n moedergesentreerde benadering word verskaf. HEALTH SA GESONDHEID Vol.13 No.1 - 2008 55 INTRODUCTION It was further indicated that this does not necessarily mean introducing more rules and centralised processes, The Limpopo Province consists of six districts, namely; or micro-managing service delivery activities. Rather, it Capricorn, Mopani, Bohlabela, Vhembe, Sekhukhune involves creating a framework for delivery of public and Waterberg. Each is further divided into sub-districts services which treats citizens more like customers and and municipalities. As indicated in the Department of enables them to hold public servants to account for the Health Reports (2002:52), the total population in the services they render. province is 5.514 million of which 54% were females. Of the total female population, 45% were in the The White Paper on Transforming Service Delivery childbearing age group. The health service structure (Department of Public Service and Administration: 1997) consisted of one (1) tertiary institution, six (6) districts through the eight Batho-Pele Principles (consultation, hospitals (level 2) and thirty-six (36) community service standard, courtesy, access, information, hospitals (level 1). The tertiary hospital is a referral openness and transparency, redress and value for hospital for levels 1 and 2 hospitals within the Province. money) aim at improving the entire standard of the public In the Limpopo Province more mothers currently give service and effective service delivery. Services should birth in hospitals than at home. According to the be based on a customer-orientated framework. Department of Health Report (2002:52), the Province had a total of 43 hospitals, of which 40 had functioning Sandall (1995:201) is in support of customer-oriented maternity units for deliveries and an estimated 64% of service delivery when he points out that the philosophy births occurred in the hospitals. and focus should shift from technologisation to personalisation, and to creation of the paradigm of a When mothers enter the hospital to give birth they are woman-centered practice based on equal partnership usually unfamiliar with both the surroundings and the between mothers and attending midwives. structure of the ward and they are not well acquainted with the rules that govern behaviour in the obstetric unit PROBLEM STATEMENT setting. The policies and procedures are strategically placed in the ward and midwives seem to regard it as The challenges posed by the utilisation of the biomedical their responsibility to ensure that the rules are adhered model are that attending midwives tend to continue to to. Such standardised routines do have some merit, view mothers as physical beings and pay little attention but when followed without skilled assessment they may to the broader characteristics of human nature. Mothers pose the risk of depersonalising the mothers and seem to have limited powers compared to their discouraging any participation and involvement during attending midwives who focus mainly on completing midwifery care (Pearson, Vaughan & Fitzgerald, certain tasks before handing over the report to the next 1998:34). The care becomes midwife-centered and not midwife on duty. Thus little effort is expended on meeting patient-centered. It might become more important for the needs of mothers as individuals. the midwives to meet their own needs and solve their own problems instead of that of the woman in labour. Once mothers seek midwifery care during childbirth, they are expected to follow set standards and midwifery The pressure from society and increased understanding protocols, because the midwives follow set standards of human rights through the Patients’ Charter and Batho- of procedures to monitor and regulate physiological Pele Principles have highlighted the restrictive nature developments. While these policies and procedures of the biomedical model, the alternative approach being might make sense from the standpoint of midwifery care the provision of woman-centered care. The Batho-Pele and possibly also reflect the priorities dictated by the Principles seek to introduce a customer-focused biomedical model, they do not always manifest the approach that aims at putting pressure on systems, experiences, needs and priorities of mothers during procedures, attitudes and behaviour within the childbirth childbirth. It is therefore important to determine how units and re-orienting the attending midwives in the mothers experience the care that they receive during customers’ favour, an approach which puts people first (Department of Public Service and Administration, 1997). 56 HEALTH SA GESONDHEID Vol.13 No.1 - 2008 childbirth. A qualitative design was chosen for this project, as the focus was on exploring and describing the experiences PURPOSE OF THE STUDY of childbirth by mothers. The research thus aims to provide a description and an exploration of a particular The aim of this study was to explore and describe phenomenon or experience, within the context of the experiences of mothers during childbirth in a tertiary phenomenon’s specific setting and world significance hospital in the Limpopo Province. This would be done by using a phenomenological research method. as a first step towards eventually developing a mother- centered childbirth model that would be utilised to assist Population and sampling the attending midwives in the facilitation of mutual participation when managing mothers during childbirth The population consisted of all mothers who had been (The model will not be discussed in this article). admitted to deliver their babies in the obstetric unit of a tertiary hospital in the Capricorn district, Limpopo DEFINITIONS OF TERMS Province. Non-probability, convenience sampling was used in the study. Concepts used in this study are defined as follows: Mothers were selected from the obstetric unit of one Experience hospital in the Capricorn district in the Limpopo Province. This hospital was used as it is an obstetrical Experience is an event or circumstances undergone or referral hospital for all six districts in the Limpopo lived through (Oxford English Dictionary, 1999). It is Province. The researcher selected available mothers in directly related to a person’s internalisation of an event, the first stage of labour who meet the inclusion criteria. which he/she has personally lived through. In this study The mothers who were selected were interviewed in experiences include emotions, thoughts, preferences, the post-natal ward within 24 hours after delivery. The perceptions and values. interviews were held in the post-natal ward to enable mothers to describe their experiences of all three stages Childbirth of labour. In this study childbirth refers to the process when a The criteria for inclusion were mothers: mother gives birth to a child, and includes the first, • with a term pregnancy; second and third stages of labour. It includes all vaginal • in early active labour, who went through the first, births. second and third stages of labour in the hospital; • with the presence of a fetal heart rate; and Biomedical Model • that should have been able to understand and speak English. Biomedical model refers to the model on which nurses base their practice and view patients as biological beings In this research the adequacy of the sample was and pay little attention to the wider characteristics of attained when sufficient data had been collected so human nature (Pearson, Vaughan & Fitzgerald, that saturation occurs and variation is both accounted 1998:27). It refers in this study to the midwife taking for and understood. According to Glaser and Strauss full responsibility for controlling the childbirth process (in Strauss and Corbin, 1990:188) saturation means without the mother participating and sharing that no new or relevant data seem to emerge regarding responsibility. a category, the category development is dense and the relationship between the categories are well RESEARCH METHODOLOGY established. Twenty-four mothers were sampled when saturation was achieved. Research design and methods of data collection Data collection HEALTH SA GESONDHEID Vol.13 No.1 - 2008 57 Permission to gain entry into childbirth units was well, so no changes were made to the question and obtained following approval from the Ethics Committee interview procedure. This patient and interview were of the Rand Afrikaans University, the Provincial therefore added to the main sample. Department of Health, and the hospital concerned. The project was explained to the unit managers, attending Data analysis midwives and mothers of the obstetrical and postnatal wards. Written informed consent was obtained from Tape recordings of the interviews were transcribed mothers. verbatim in the language in which the interviews were held. The narrative data from unstructured in-depth Unstructured in-depth interviews were conducted in interviews were analysed qualitatively through the open English with the mothers. The question directed at the coding method (Tesch, 1990, cited in Creswell, mothers was: “Could you please tell me about your 1994:155). Data analysis is a process of bringing order experiences of childbirth in this hospital?” to the data and organising what is collected into concepts, categories and basic descriptive statements The researcher contacted each participant in the post- (Patton 1987:144). natal ward to confirm an appointment for the interview at a quite place in the post-natal ward and at an Another person was requested to also analyse the data appropriate time for the participants. The interviews were according to Tesch’s method (Tesch, 1990, in Creswell, tape-recorded and comments were made about 1994:155), independently from the researcher. The two sensitive ethical issues such as maintaining analyses were then compared to ensure confidentiality of data and preserving the anonymity of trustworthiness. The other analyser was selected as the informants and using research for its intended she had experience in qualitative research methodology. purposes (Creswell, 1994:148). The tapes were numbered and the participants’ names were nowhere TRUSTWORTHINESS mentioned. The ethical standards as set by DENOSA (Democratic Nursing Organisation of South Africa) were The four criteria of trustworthiness, namely, credibility, adhered to before and during the interview (DENOSA, dependability, transferability and applicability, as 1998:1-7). outlined in Lincoln and Guba (1985:301-318) were used to establish the trustworthiness of this study. The researcher created a context that was conducive to mutual trust between researcher and participant. To enhance credibility the researcher: Other ethical issues that were considered were the • had prolonged contact with the study field. She following: Privacy was ensured during the interview. The was a midwife, who had knowledge and clinical participants were ensured that their participation is experience in this area. The literature that was entirely voluntarily and that they could withdraw from consulted enabled her further to satisfy the criterion the research at any stage if they feel so. The interviews of being knowledgeable about the phenomenon would be stopped if the participant suffered severe stress under investigation; during the interview. The possibility of referring the • bracketed existing knowledge and preconceived patients for counselling was discussed with the patients ideas and especially personal views about the after the interview. During the interview communication existing problems in the clinical area; and skills for example probing was used to obtain the • conducted the unstructured interviews until data necessary information. saturation occurred, namely until the collected data were repeated and confirmation of previously A pilot study was conducted with one mother to refine collected data took place. the question. The question was asked to one mother and the interview was conducted as planned. The reason The categories identified by the researcher were was to see whether the question was clear to the mother compared with those identified by the other coder. No and whether the interview developed as planned. The major discrepancies were identified between these mother understood the question and the interview went persons’ analysis of the data. An in-depth literature 58 HEALTH SA GESONDHEID Vol.13 No.1 - 2008 review further confirmed these categories. This I can participate.” “They know what to do and how to enhanced confirmability. care for us during labour but at times I just felt I’m not involved because I’m just told what to do without being Transferability was ensured by the researcher providing asked. I don’t want to be restricted”. in-depth discussions of the data obtained, data analysis and interpretation of the research findings in a research According to Berg, Lundgren, Hermansson, and report. Wattberg (1996:15) mothers are said to have had negative experiences when they lose control of the ETHICAL CONSIDERATIONS situation and are not able to participate in the decision- making. They further indicate that this occur in Ethical considerations were based on the DENOSA situations where midwives take control without giving Ethical Standards for Nurse Researchers (1998:2.3.2- the mother the necessary time to be involved. Lundgren 2.3.4). The different ethical issues were referred to under and Dahlberg (2002:158) point out that it is important data gathering. for midwives to collaborate by inviting the mothers to participate and be responsible for their care during FINDINGS AND DISCUSSIONS childbirth. The results from the experiences of the mothers during Some of the mothers, on the other hand, were childbirth revealed five (5) themes, with their sub- comfortable with their dependency on the midwives as categories. The themes are not given names, but are they indicated that midwives are trained practitioners referred to as theme 1, for example. The categories and they know best. The mothers mentioned that they under the themes were then given descriptive names. did not have anything to say, but to listen to the See Table 1: midwives. The following quotes were cited by mothers: “During childbirth I was following all the instructions as Theme 1: Mutual participation, was instructed by the sister because the sister has responsibility sharing, dependency and knowledge and I’m ill”. “No, during childbirth I don’t have decision-making anything to say, but I must listen to all what midwives says”. The transcripts of the mothers indicated that there was limited participation and collaboration between them Since the mothers depended on the midwives, it was and the midwives during childbirth. The mothers were evident that they had limited decision-making capability. of the opinion that the midwives did not involve them One mother participant indicated that she was willing when providing midwifery care as they just instructed to take part in the decision-making, but lacked factual them on what to do and also pointed out that the or accurate information with regard to the available midwives were not friendly. The following quotes from options, as the following quote indicates: “I would be the mothers’ interviews support this feeling: “I was not very happy to be involved in decision-making during involved and not informed about my progress, the childbirth, but this was not the case and we need to be midwives will examine me and I will only overhear them given more information on all issues relating to childbirth giving each other the report, but not telling me so that because if we are having information we can decide Table 1: Themes and sub-categories THEMES 1. 2. 3. 4. 5. Mutual participation Information sharing Open Accommodative/No Maximize human SUB- and responsibility and empowering communication and n-accommodative and material CATE sharing, autonomy and listening midwifery actions infrastructure GORIES dependency and informed choices decision-making HEALTH SA GESONDHEID Vol.13 No.1 - 2008 59 From the interview transcripts of mothers, language and make informed choices”. barriers were cited as a factor that interfered with their interaction during childbirth (especially to mothers who Bluff and Holloway (1994:160) point out that women were transferred from other hospitals and who used place themselves in the hands of midwives and allow different languages from that of the attending midwife) midwives to make decisions for them even if their own because the tertiary hospital provides midwifery care wishes are neglected. Nolan (1997:1201) further to all racial groups. Some of the mother participants indicates that midwives are challenged to enforce equal revealed that midwives were impatient, did not listen to opportunities of making information available and to them and seldom verified why they had specific encourage mothers to take responsibility for their own preferences. The mother participants felt that the care. Gibbins and Thomson (2001:310) indicate that attending midwives lacked listening skills which being included in and making decisions are reported hindered verbal communication during childbirth as the as being crucial in helping mothers feel in control during following remarks made by the interviewees revealed: childbirth. “Some midwives must be patient and at least listen to what I want to say, they have knowledge and I know Theme 2: Information sharing, that they are busy but even if you ask a small thing empowering, autonomy and informed they won’t listen. For example, if you indicate the choices preference they don’t allow or even listen to why you make such a preference” and “Hmm … I didn’t clearly When information is shared with regard to childbirth understand the language of the midwife, but I would issues and available childbirth options outlined, mothers like to be assisted especially if there are complications”. would be empowered. The mothers emphasised that they were lacking factual information on childbirth Theme 4: Accommodative midwifery issues and on available birth options or choices. They actions also did not have a good understanding of the available options which they could exercise as the right to choose Nolan (1997:1201) suggests that women need to be during childbirth. The following excerpt from some of given information and the opportunity to discuss how the mothers’ interviews was cited with regard to available that information relates to their particular circumstances options and childbirth issues: “(Laughing …) I don’t before the stresses of labour make it unrealistic to enter know what to expect and what is going to happen during into detailed considerations of the pros and cons of childbirth, the midwives and doctors know exactly, they childbirth. Contrary to this, the mothers indicated to are able even to determine the complications early and the midwives that they wanted to be respected and to prevent them”. treated as adults. “I expected good care from the midwives. They must treat me as a person, listen to A lack of shared information was thus seen as an me and empathize with me as I was feeling pain” and obvious concern. Halliday and Hogart-Scott (2000:63) “During childbirth there should be communication as well as Gibbins and Thomson (2001:302) state that between the midwife and myself, they must listen and there are many expressions of the need for information, clearly explain to me if what I prefer is not possible”. reassurance and confidence building. They further point out that information given during childbirth enables the The mothers indicated that they would prefer the mother to take decisions and empowers her to make presence of a companion, but were not informed that informed choices. In addition, Richter, Greaney, this was possible as the following expression indicate: McKeown, Cornell, Littleton and Pulley. (2001:174) point “If I knew that my partner could be allowed in, I would out that if women are not given adequate information, have loved that so that he can witness how the baby is they may not be able to collaborate with their physicians delivered and I think this will strengthen the bond or be willing or able to ask questions. between the two of us” and “My partner should be present, he must see how pain is, and he must be Theme 3: Open communication and involved and understand how painful childbirth is … listening 60 HEALTH SA GESONDHEID Vol.13 No.1 - 2008 and he will agree if I opt for sterilisation”. unit. The strict routines that are laid down by the regulations seem to depersonalise the mother, re- Several authors have spelt out clearly the advantages sulting in her non-participation. Midwives impose of the presence of a companion during childbirth their authority and responsibility to ensure that the (Micklethwait, Beard & Shaw, 1978:190; Somers-Smith, rules are adhered to. Mothers are merely seen as 1999:105). However, Nolan (1997:1198) points out that the ones who should comply with the rules of the in most parts of the world childbirth is a female issue unit while having no power of decision, and there is and in the vast majority of traditional cultures it is an over-reliance on technology. unheard of for men to be present at birth. • Limited information sharing and empowering is displayed in this approach, that is, information Theme 5: Maximise human and material regarding childbirth issues and awareness of infrastructure available options are not shared with the mothers which result in powerlessness and a lack of A shortage of staff was cited in the interview transcripts. autonomy in childbirth care, this therefore also limits It was pointed out that one midwife would be caring for their ability to take independent decisions. more than two mothers at the same time. Midwives • Hindered/ineffective communication, for example, were not able to spend quality time with the mothers inadequate listening skills of attending midwives and to verify their preferences. Pelkonen, Perala and and the existence of a language barrier between Vehvilainen-Julknnen (1998:22) state that a busy and mothers and midwives often result in limited routinised atmosphere has been found to inhibit participation by the mothers. The midwife-centered participation, whereas a friendly, peaceful and secure care approach seems to limit itself to the situation provides opportunities for participation. Staff physiological processes and the psychosocial shortages do contribute to a feeling of tension in clinics aspects of the mother are thus ignored. and on the wards (Micklethwait et al. 1978:190). • Non-accommodative midwifery actions with regard to poorly defined perceptions of conflicting Almost all the mothers agreed that they valued the expectations and unrealistic choices of the mother presence of a midwife who gave detailed information on were manifested. In midwife-centered care, the what to expect and about the progress of the labour. management of childbirth is focused on the Tarkka, Paunonen and Laippala (2000:188) support this detection of complications, which does not always by stating that for the attending midwives to influence respect the experience and expectations of the mothers’ positive childbirth experiences; they should childbirth and its outcome. display empathy, friendliness, tenderness, calmness, alertness, peacefulness and professional expertise. LIMITATIONS OF THE STUDY CONCLUSION There are no limitations of the study except possible bias of the persons who did the analysis and The results of the interviews seemed to have revealed interpretations of the data. midwife-centered care rather than mother-centered care during childbirth in the unit of the tertiary hospital in the RECOMMENDATIONS Capricorn district of the Limpopo Province. In midwife- centered care, it is the midwife who tells mothers what The recommendation is thus to create a model of to do and how to behave. This approach during childbirth mother-centered care that is based on equal partnership is characterised by: between the mothers and attending midwives. The procedures to obtain the mother-centered care should • Limited mutual participation and responsibility be described in detail in this model. sharing, which comprise of inadequate participation, The mother-centered care approach during childbirth, limited decision-making scope and a proliferation described in this model should be characterised by: of practices that foster dependency, and a • Participation that requires a mutual, egalitarian and prevailing authoritative approach within the childbirth respectful relationship. Equality includes the HEALTH SA GESONDHEID Vol.13 No.1 - 2008 61 principle of sharing power and responsibility. There Journal, 2:188-191. should be leverage for negotiation between the NOLAN, ML 1997: Antenatal education - Where next? Journal of mother and the midwife. Advanced Nursing, 25(6):1198-1204. • Sufficient information provided by the attending OXFORD ENGLISH DICTIONARY 1999: University Press. midwives and which is a prerequisite for decision- PATTON, F 1987: Qualitative evaluation and research methods. making. Newbury Park: Sage. • Interaction between the mother and the midwife PEARSON, A; VAUGHAN, B & FITZGERALD, M 1998: Nursing should enhance the self-esteem and self- models for practice. Melbourne, Johannesburg: Butterworth- determination of the mother. The midwife and the Heinemann. mother should listen to each other because they PELKONEN, M; PERALA, ML & VEHVILAINEN-JULKNNEN, K 1998: engage in a dialogue to identify preferences and Participation of expectant mothers in decision-making in maternity expectations so that a new strategy for change is care: results of a population-based survey. Journal of Advanced constructed. 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