A woman's physiological instinct to assume upright positions during labour and birth is increasingly challenged in hospital settings, despite recommendations from the World Health Organization (2018) that women should have the autonomy to adopt any position deemed safe and comfortable during birth. Acknowledged as an evidence-based practice, adopting upright birth positions is known to positively impact maternal and fetal birth outcomes (Deliktas and Kukulu, 2018; Huang et al, 2019), yet labouring women are often encouraged into supine or semi-recumbent positions, which are known to increase the likelihood of epidurals and obstetric intervention (Gizzo et al, 2014). While medical intervention is acknowledged to be beneficial at times, the risk of these becoming routine practices has undoubtedly influenced the normal processes of birth (Gizzo et al, 2014; Lee and Tracy, 2019). Arguably, the rise in perineal trauma, prolonged labours (Huang et al, 2019) and increased rates of assisted birth worldwide (Atsali and Russel, 2018) are evidence that medical intervention during labour and birth are increasingly common practices.
This integrative review aimed to provide valuable insight into the factors that impact a woman's capacity to adopt upright birth positions in clinical settings, and also explores the influences of maternity staff in this context.
Methods
This review followed the recommendations of the preferred reporting items for systematic reviews and meta-analysis (PRISMA) checklist (Moher et al, 2009), the Critical Appraisal Skills Program (2018) checklists and a series of articles outlining the step-by-step approach to conducting systematic reviews published by the Joanna Briggs Institute (Aromastaris and Pearson, 2014; Aromastaris and Riitano, 2014; Munn et al, 2014; Porritt et al, 2014; Robertson-Malt, 2014; Stern et al, 2014).
Search strategy
The focus of this search strategy was to locate published literature relevant to the review question ‘what factors prevent women from adopting upright birth positions in hospital settings?’ As outlined by Aromataris amd Pearson (2014), a logic grid was developed to identify keywords derived from the review question (Table 1).
Table 1. Logic grid adapted from Aromataris and Pearson (2014)
| Population | Phenomenon of interest | Context |
|---|---|---|
| Wom*“Pregnant women” | “Upright birth positions”“Birth positions”“Maternal positions”“Delivery positions”“Labour positions”“Labor positions”Barrier*Obstacle*Challenge* | Hospital*“Clinical environment”“Birth suite”“Clinical setting* |
When combined, these formulated a search string that was then entered into two accredited electronic databases: the Cumulative Index to Nursing and Allied Health Literature and MEDLINE. Following this, an extensive manual search by citation was conducted to retrieve additional literature that was not found in the initial search. This also included a search through the end reference lists of all articles meeting the inclusion criteria. The articles eligible for review had to have been peer-reviewed, published between 2014 and 2020 in English, with the full text available. The complete search and screening process is presented in Figure 1.
Critical appraisal
Critical appraisal was completed using the Critical Appraisal Skills Program (2018) checklist for qualitative research. The methodological rigor of each potential article was assessed against a set of 10 questions derived from three broad issues used to appraise the validity of a qualitative study. The first issue asks if the results are valid:
- Was there a clear statement of the aims of the research?
- Is a qualitative methodology appropriate?
- Was the design appropriate to address the aims?
- Was the recruitment strategy appropriate to the aims?
- Were the data collected in a way that addressed the research issue?
- Has the relationship between researcher and participants been adequately considered?
The second asks what the results were, by asking ‘have ethical issues been taken into consideration?’, ‘was the data analysis sufficiently rigorous?’ and ‘is there a clear statement of findings?’. The third asks whether the results will help locally, asking ‘how valuable is the research?’
Four articles were excluded as they did not adequately meet the checklist criteria, were deemed irrelevant or inappropriate to the review question and selection criteria or because they did not provide adequate descriptions of the study conducted. Four articles were retained for inclusion in this review (Table 2).
Table 2. Articles included in this review
| Author(s) and title | Journal and year of publication | Countries represented | Methods | Key findings |
|---|---|---|---|---|
| Atsali and Russell Hospital midwives' barriers when facilitating upright positions during a normal second stage of labour | Africa Journal of Nursing and Midwifery (2018) | Africa USA Netherlands Australia Ireland | Critical review of the literature including qualitative and quantitative evidence | The medicalisation of birth engenders a practice that is dominated by medical policies and procedures, thereby making it difficult for midwives to offer women alternatives to bed birth.The midwifery labour ward culture together with an expectation that practitioners would conform to perceived norms further inhibited midwives' promotion of upright positions during labour and birth |
| Green Exploring the influence that midwives have on women's position in childbirth: a review of the literature | Evidence Based Midwifery (2015) | Netherlands USA Australia Sweden | Systematic review including qualitative and quantitative evidence | Midwives support women in upright birth positions. Midwives who prioritise women's preferences over their own also facilitate upright birth positions. Supine positions are associated with midwives' lack of training or experience, and prioritisation of their own comfort.Contextual factors influencing midwives' practice include clinical conditions such as length of labour and the nature of the midwife-client relationship |
| Mselle and Eustace Why do women assume a supine position when giving birth? The perceptions and experiences of postnatal mothers and nurse-midwives in Tanzania | BMC Pregnancy and Childbirth (2020) | Tanzania | Qualitative research employing a descriptive qualitative study design: semi structured interviews and focus groups | Women use the supine position during childbirth because they are instructed to do so by the nurse-midwives.Midwives commonly decide birthing positions for labouring women and supine position is the best-known birthing position.Supine birth positions provide midwives flexibility to continuously monitor the progress of labour and assist delivery most efficiently |
| Musie et al Factors hindering midwives' utilisation of alternative birth positions during labour in a selected public hospital | African Journal of Primary Health Care and Family Medicine (2019) | South Africa | Qualitative study employing exploratory and descriptive research design | The lack of skills and training during the midwifery undergraduate and postgraduate programme contributes to the midwives being incompetent to use alternative birth positions during clinical practice |
Data extraction and analysis
Data extraction and thematic analysis was conducted using Braun and Clarke's (2006) approach. This involved initial familiarisation with the data, coding of key findings and grouping emergent themes and patterns into meaningful categories.
Results
Three core themes emerged from the dataset, which were derived from five subthemes (Table 3). The core themes were ‘the biomedical model of care and workplace culture impact the positions women adopt during labour and birth’, ‘midwives’ philosophy and views support physiological birth’ and ‘clinical settings are not conducive to physiological birth’. Together, these findings present the factors that both help and hinder women's capacity to assume upright positions in clinical settings and the impact this has on physiological birth.
Table 3. Summary of core themes and subthemes
| Core themes | Subthemes |
|---|---|
| The biomedical model of care and workplace culture impact the positions women adopt during labour and birth | Workplace culture is seen as a barrier to physiological birth |
| Midwives' philosophy and views support physiological birth | Midwives are highly influential to pregnant and labouring womenMidwives' attitudes, skills and confidence are factors that influence physiological upright birthWomen lack knowledge of physiological birth and antenatal education on birth positions is limited |
| Clinical settings are not conducive to physiological birth | The design of clinical settings is not conducive to facilitating upright birth |
The medical model of care and workplace culture impact labour and birth positions
The influence of the medical model of care within clinical settings were evident in all four articles included in this review (Green, 2015; Atsali and Russell, 2018; Musie et al, 2019; Mselle and Eustace, 2020). Within these contexts, midwives were reportedly more likely not to offer women the choice of upright birth positions, even when requested by the woman (Atsali and Russell, 2018). The medical model was also described as fragmented and led by obstetric policies, which were often unsupportive of physiological birth (Atsali and Russell, 2018). Maternity staff were also noted to focus on delivering routine interventions such as cardiotocograph monitoring and vaginal examinations, which were used to persuade labouring women into supine positions or to remain on the bed (Green, 2015; Atsali and Russell, 2018).
Workplace culture is seen as a barrier to physiological birth
Workplace culture was reported a barrier to upright birth in two of the included articles (Atsali and Russell, 2018; Musie et al, 2019).
‘The conformity of midwives and women to hospital routines and practices [was] an important determinant of actual behaviour.’
‘I place the woman in the lithotomy position because it's what I find being done in the unit.’
Despite some midwives acknowledging they were taught about optimal birth positions, midwives reported they did not use alternative birth positions.
‘I never practice alternatives [positions], I guess we just…adopted the [routine] culture.’
(Musie et al, 2018)
Green (2015) reported similar findings, suggesting midwives were more likely to support supine positions for clinical procedures and assessments during labour, such as routine cardiotocograph monitoring, as it was the norm for institutional policy.
Power and coercion were thought to dominate the practices and behaviour of midwives working in these contexts. This hierarchy impacted the culture of birth environments, at times leaving midwives struggling to be compliant and fearing consequences if they acted autonomously (Atsali and Russell, 2018).
‘Midwives tend to work within a hierarchical system with the obstetrician at the top, followed by the senior midwife then the junior midwives and finally the women.’
All articles in this review included midwife participants who admitted to prioritising their own comfort over the woman's preference to adopt an upright position during birth (Green, 2015; Atsali and Russell, 2018; Musie et al, 2019; Mselle and Eustace, 2020). This highlighted the potential for power imbalances between midwives and women.
‘My view on alternative birth positions is it can only be done if the midwife is comfortable with it.’
Similarly, Mselle and Eustace (2020) reported midwives felt more knowledgeable than women in regard to birth practices and as such determined the appropriate birth position.
‘It is difficult to allow [the woman] to use her preferred position because the midwife is the one who knows the best birthing position.’
Midwives' philosophy and views support physiological birth
Midwives were recognised as being highly influential to labouring women, with women reporting midwives to be the most influential factor when considering birth positions (Green, 2015; Atsali and Russell, 2018; Musie et al, 2019). As such, midwives' attitudes towards upright physiological birth are influences most likely to impact the positions women adopt during labour. While the skills and knowledge of midwives were at times recognised as a barrier to upright birth, so too was that of women, with a lack of knowledge about upright birth positions perceived by women to be a factor that further compounded this issue (Musie et al, 2019).
Notably, midwives working within continuity of care services were more likely to encourage women to adopt the birth position of their choice (Atsali and Russell, 2018). Midwifery-led models were also associated with information-sharing between women and midwives, which led to midwifery practices that accommodated women's preferences to adopt upright birth positions and information on the benefits of physiological birth (Green, 2015).
Midwives are highly influential to pregnant and labouring women
The majority of articles included in this review recognised the midwife as influential to women adopting upright positions during birth (Green, 2015; Atsali and Russell, 2018; Mselle and Eustace, 2020).
‘Women perceive midwives' influence as the most important factor when considering birth positions.’
Similarly, midwives were described to positively influence a woman's birth position by encouraging them to remain upright and being creative within the birth space (Green, 2015).
Midwives' attitudes, skills and confidence are factors that influence physiological upright birth
This category highlights the influence of midwives' views towards upright birth and their confidence to support such practices. Atsali and Russell (2018) reported some midwives felt deficient in skills to confidently facilitate upright birth. Similarly, Musie et al (2019) suggested midwives lacked the confidence to support physiological birth because of limited training. Some midwives also reported they promoted supine birth as their preferred position, deeming this mode more convenient for managing obstetric complications (Green, 2015; Atsali and Russell, 2018; Musie et al, 2019; Mselle and Eustace, 2020).
Women lack knowledge of physiological birth and antenatal education on birth positions is limited
Attending antenatal classes significantly contributed to women feeling better informed about upright birth positions, which increased women's preference to assume such positions during birth (Green, 2015). Women's knowledge of the benefits of upright birth positions was further enhanced through continuity of care and discussion with their midwives (Green, 2015). Other findings suggested women were not provided with information regarding upright birth positions during parent education sessions.
‘We did not receive any education on alternative birthing positions…but our friends tell us about different birthing positions.’
This was reportedly an issue for midwives as well, who commented on their increasing workloads, which impinged on the time midwives had to provide antenatal education, assessment and information sharing (Musie et al, 2019).
Clinical settings are not conducive to physiological birth
A significant finding of this review suggested that midwives feel that clinical settings are not conducive to supporting upright physiological birth. The limited availability of equipment and resources (ie fit balls, birth stools, birth pools) to promote such practices in birth environments was also noted.
The design of clinical settings is not conducive to facilitating upright birth
A woman's birth environment can have a psychological impact on her labour and birth (Atsali and Russell, 2018). Atsali and Russell (2018) and Green (2015) concurred, suggesting that hospital birth spaces were more likely to be designed with additional technologies to meet the needs of women requiring complex care, limiting room for both women and midwives to move.
Discussion
The findings of this review confirm maternity care in clinical settings continues to be dominated by the medical model of care. This is evidenced by workplace cultures governed by risk-aversion, policies that at times may not reflect evidence-based practices and limited time to educate women and train midwives on positions that promote physiological birth. Midwives were found to significantly influence the positions women adopt during labour and birth, with midwives' views towards upright birth, and their skillsets to support such positions, directly impacting the provision of upright birth practices.
In this review, midwives' knowledge and experience of upright birth was varied, with an evident gap in both training and confidence to support women to birth in upright positions. This also influenced the education women receive antenatally, with most women and nurse-midwives reporting limited opportunities for discussion and education about optimal birth positions during antenatal appointments. These findings bring to light midwives' workloads and the limited capacity midwives and obstetric nurses have to adequately educate women on such practices in hospital settings. While midwifery-led care and other continuity of care models were recognised as facilitators of upright birth, the attitudes and skills of most nurse-midwives working in hospital settings were influenced by the medical model of care. This highlighted the use of routine intrapartum interventions that at times did not appear to be woman-centred, evidence-based or protective of physiological birth.
A substantial finding emphasises the importance of functional hospital birth spaces, with cluttered birthing rooms and limited access to resources highlighted as a core challenge for midwives wanting to support women to experience an upright physiological birth. This finding resonates with Hammond et al (2017), who identified three key design characteristics that support midwifery practice: friendliness, functionality and freedom to move spontaneously and practice responsive midwifery care.
While the benefits of upright birth positions were well recognised in this review, so too were the risks associated with supine positions. Semi-recumbent and lithotomy positions were acknowledged to increase the risk of perineal trauma, maternal pain, prolonged labours, abnormal fetal heart rate patterns and the likelihood of assisted birth (Atsali and Russel, 2018). This is consistent with work by Gupta et al (2017), who reported women who used upright birth positions during labour were 25% less likely to experience an instrumental birth, 25% less likely to receive an episiotomy and, notably, experienced a significant reduction in pain during labour and birth. The use of oxytocics and schedule eight pain relief (eg epidural, morphine) was also increased, leading to additional risks for maternal and fetal wellbeing (Tracy, 2019).
Limitations
Although every effort was made to ensure this review presents findings based on best available evidence, the authors acknowledge key issues arising from this review. It is possible that pertinent studies relevant to the phenomenon of interest were missed for inclusion, the findings were based on four articles and consequently may limit the transferability of evidence across different midwifery contexts or countries, and it is plausible that articles in languages other than English may have provided additional insight into the review findings.
Conclusions
This integrative review makes a valuable contribution to the body of evidence on the phenomenon of interest by highlighting key findings. An evidence-to-practice gap persists regarding the education midwives and women receive in the antenatal period on the benefits of adopting upright positions during labour and birth. Further development of policies that facilitate upright birth must be embedded into routine care practices in clinical areas and adequate education and training for midwives and obstetricians, as well as antenatal education programs for pregnant women, will raise awareness of upright birth positions and likely foster positive attitudes towards supporting upright birth in clinical practice.
Key points
- In hospital environments where birth occurs, midwives experience tensions between the medical model of care, adhering to clinical guidelines and practicing evidence-informed care.
- Normalising physiological birth for women in hospital environments is crucial for the future of evidence-based maternity services.
- For this to occur, the gap between clinical practice guidelines and evidence-based practice in birth environments must be addressed.
- Improving education and training for midwives, as well as pregnant women, will raise awareness of the benefits of upright birth positions and likely foster positive change in hospital birthing environments.
CPD reflective questions
- Do your workplace policies and guidelines reflect evidence-based practice, and do they align with your own midwifery philosophy?
- What practices can you identify in your workplace that require updating or improvement to align with latest evidence?
- What strategies can you employ to initiate the updating or improvement of evidence-based practice in your workplace?
- Does your workplace support evidence-based change, what helpers and hindrances can you identify?
- How can midwives ensure women remain the centre of all care in birth environments?