In Brunei, inappropriate admission of pregnant women to delivery suites can cause overcrowding, which can affect the quality of the maternity services provided by maternal and child healthcare facilities. This article discusses the factors that can affect a woman's choice in when to present to a delivery suite and the importace of antenatal education in ensuring mothers present at the appropriate time during labour.
Maternal and child healthcare services in Brunei
Brunei is a higher income nation in southeast Asia where approximately two-thirds of its population are of Malay origin (Abdul-Mumin, 2016). It has a population of 459 500 with an estimated 6000 births per year. Brunei became a member of the United Nations and World Health Organization (WHO) immediately after gaining independence from being a British protectorate in 1984 (Yusof, 2017). The improved socioeconomic status of Brunei has been linked to a reduction in maternal mortality and morbidity (Ministry of Health, 2018). The Brunei government, through the Ministry of Health (2021), offers comprehensive public medical and health services free of charge, including maternal and child healthcare facilities. There are four public hospitals in Brunei, the central referral hospital being in the capital city. The other three hospitals are purposely designated for the population in the other three districts. Maternal and child healthcare is also provided in a sophisticated private hospital equipped with modern technology in Jerudong. The primary healthcare centres that provide maternal and child healthcare services consist of 17 health centres, five travelling health clinics and two flying medical services (Ministry of Health, 2021).
In Brunei, on average, each woman attends 7–10 antenatal visits during pregnancy (Office of International Cooperation, 2008), well above the WHO (2016) recommendation of four visits during pregnancy and in line with the updated recommendation of at least eight visits (WHO, 2016). Professional maternity healthcare providers, comprising community health nurses, midwives and nurse midwives, provide care and advice to women during pregnancy, labour and the postpartum period in Brunei. According to the Ministry of Health (2017), more than 90% of pregnant women receive antenatal services and the majority of women give birth in hospitals. However, there are cases of women giving birth at home in rural areas where healthcare services are not readily available. Women who believe they are in labour are allowed to come to the delivery suites at hospitals for further management. Based on the assessment and evaluation made, they will be triaged accordingly, and either be admitted or sent home.
There is increasing concern that some women are inappropriately admitted – they are not in active labour and therefore, do not require immediate admission. As a result, pregnant women are transferred to the antenatal ward for further assessment and observation. This has led to inappropriate admission to the antenatal ward and resulted in unnecessary bed occupancy. These beds may be needed for other pregnant women.
There is anecdotal evidence to suggest that midwives who work in labour rooms in Brunei experience frustration because some pregnant women do not use the ‘maternal and child health handbook’ provided. Information about the signs and symptoms of labour and when to come to the labour room or delivery suite is given in the handbook for pregnant women to refer to prior to deciding to present to the labour room.
Although this scenario is typical in Brunei, the evidence is based on collective anecdotal experiences of midwives, meaning research-based evidence is needed to address inappropriate admission to the labour room or ward. A recent study conducted in Brunei on the use of the handbook found that some women felt insecure and vulnerable, voicing the need to hear affirmations directly from a healthcare provider in order to validate their experiences (Luta, 2021). The study recommended that in order to encourage and educate women, their families and society to view labour as a normal phenomenon and not something that must be managed or controlled, women and their families should first be equipped with evidence-based information and knowledge on the latent phase of labour.
Fear in labour and admission to delivery suites
Jackson et al (2003) described the onset of labour as the presence of intense, regular and painful contractions that result in the progression of cervical effacement and dilatation. Diagnosing labour is difficult but a critical decision or judgement needs to be made by midwives or maternity healthcare providers (Hanley et al, 2016). An incorrect diagnosis may lead to issues such as multiple visits to a hospital. There are also risks of unprecedented labour that may endanger both the mother and baby's health.
Several international studies have reported an increased likelihood of medical interventions when women are admitted to hospital during the latent phase of labour, such as epidural analgesia, augmentation and caesarean birth (Mikolajcyzk et al, 2016; Kobayashi et al, 2017). However, some of these interventions and their consequences could be minimised if women and midwives are equipped with the confidence, knowledge and skills to correctly diagnose labour, that may in turn contribute to a positive and affirming childbirth experience.
Women's fear typically heightens as their due date approaches, which is further precipitated by not knowing what to expect and how to react if there is sudden onset of labour. Several studies show that women's experiences of fear differ from woman to woman and in different pregnancies. A quantitative study (n=191) by Demsar et al (2018) in Slovenia reported that fear tends to be greater in nulliparous women than multiparous and that fear is related to having no control of labour experiences. These findings were reinforced by a cross-sectional study in Ireland (n=882) (O'Connell et al, 2019) that reported that fear is higher among nulliparous women (P<0.005). Additionally, it was found that overall, women fear the unknown, and their fears are multifactorial. A systematic review of 24 papers originating from nine countries in Europe, Australia, Canada and the USA (Nilsson et al, 2018) demonstrated that fear in childbirth is overly broad and there is no precise definition of fear associated with childbirth. In the same vein, a meta-synthesis of 14 qualitative studies from six different countries (Wigert et al, 2020) conclusively reported that fear is commonly and particularly influenced by insufficient knowledge of the process of labour.
The authors have recently conducted research in Brunei, which found that feelings of insecurity and pain are major reasons why women present at a hospital, even when they are not in established labour, although this study is currently unpublished. Kobayashi et al (2017) likewise noted that women's doubts and anxiety about arriving at the hospital too early or too late are reflected in their desire for validation to overcome fear of the unknown, which heightens anxiety. These feelings, the decisions that need to be made and women's uncertainty combined indicate the possibility that women's experiences are affected by the medicalisation of childbirth.
In Brunei, homebirths are occurring less frequently. Hospitalisation of childbirth began in the 1960s when there were concerns that traditional midwives and midwives appointed to work in managing home births were not able to oversee high-risk pregnancies as they did not have instruments at hand and their scientific knowledge on high-risk pregnancies was deemed inadequate (Abdul-Mumin, 2015). Today, more than 90% of births take place in a hospital (Abdul-Mumin, 2015). As such, women may perceive the hospital to be a safe place to give birth, affecting their decision on when to present to hospital.
Labour can be an exhilarating and fulfilling experience for some women, but it can also be a frightening experience that causes anxiety (Sayakhot and Carolan-Olah, 2016; Cutajar et al, 2020). Appropriate antenatal care, information and advice can have a significant impact on women throughout their childbirth experiences. One of the vital aspects of antenatal education is informing women of the signs and symptoms of the first stage of labour and on what constitutes deviation from normal labour. In addition, it is also important to educate women on how to self-manage early onset of labour at home prior to the onset of active labour that later requires professional management at the delivery suite. Therefore, antenatal education is important in pregnancy, as it enhances women's confidence and their ability to take control of their pregnancy, specifically in choosing to come to the delivery suite or labour room at the appropriate time.
Do women have appropriate antenatal education?
The importance of antenatal education
Most women find information on pregnancy and childbirth important and rely on this information to guide them through their pregnancy and birth (Gottfredsdottir et al, 2016). This information can be delivered through antenatal classes or education. Hong et al (2021) carried out a systematic review and meta-analysis of 23 quantitative studies and found that antenatal education should be standardised to elucidate mental and physical health effects. This will help to reduce maternal stress among pregnant women, improving their self-efficacy and lowering the rate of caesarean birth (Tang et al, 2021).
A phenomenographic study in Sweden (n=18) found that antenatal education prepares women for both childbirth and parenthood (Palsson et al, 2018). Women gain knowledge to form realistic expectations and education was important for women to plan for labour and beyond. Likewise, a descriptive cross-sectional design in Jordan (n=150) highlighted similar findings, as women emphasised their need for knowledge on how to identify major complications throughout childbirth and how to enhance their own and their fetus' health (Almalik and Mosleh, 2017).
A quasi-experimental and prospective study (n=192) in Turkey discovered that antenatal education improves expectant parents' knowledge on labour and confidence in when labour begins (Karabulut et al, 2016). Similarly, a secondary analysis of a national maternity survey carried out in England (n=4578) reported that women who were unable to attend antenatal classes were more likely to be worried about not knowing when labour would start (Henderson and Redshaw, 2017). This is also consistent with the findings of a Danish randomised controlled trial (n=1766), which reported that antenatal education increased women's confidence in their ability to cope with labour (Brixval et al, 2016).
A study conducted by Aji et al (2019) on antenatal education for pregnant women attending maternal and child health clinics in Brunei reported that the majority of women were satisfied with the antenatal education provided in the maternal and child health clinics and that they found the that the information provided was beneficial for prenatal care, labour and childbirth.
Antenatal education is an integral part of antenatal care as it provides an opportunity prior to birth to guide and prepare women for pregnancy and birth. Acquisition of knowledge through antenatal education has been highlighted as crucial because it helps to improve confidence, in particular when labour begins and thus, reduce anxiety.
Factors influencing antenatal education on the appropriate time to attend a delivery suite
Women's expectations and preparation for labour
Tabaghdehi et al (2020) conducted a qualitative exploratory study on 10 women in Iran to explore the meaning of a positive childbirth experience. Women felt that mental and physical preparedness play a vital role in the birth experience. Preparation helps women to recognise realistic experiences and this includes understanding pregnancy and birth and being familiar with the environment before childbirth.
Carlsson et al (2009) conducted a study on Swedish women's experiences of seeking care and being admitted during the latent phase of labour. They reported that women can become upset, impatient and agitated if they do not have enough specific knowledge or answers to uncertainties. Hence, with adequate information, women may be able to manage uncertainty which may positively affect motivation. Carlsson et al (2009) also suggested that knowing what to expect and what is considered normal or abnormal can make uncertainty easier to manage.
Palsson et al (2018) researched the importance of education for expectant parents and found that antenatal education prepares women for childbirth and parenthood. Women used knowledge as a basis to form realistic expectations and found education significant in allowing them to plan ahead for labour and beyond. A descriptive cross-sectional design among 150 antenatal women in Jordan highlighted similar findings, as women emphasised the need for knowledge on how to identify major complications during childbirth and how to enhance their own health as well as their fetus’ (Almalik and Mosleh, 2017).
A quasi-experimental and prospective study (n=192) in Turkey discovered that antenatal education improves expectant parent's knowledge on labour and their confidence when it starts (Karabulut et al, 2016). A secondary analysis of a national maternity survey carried out in England (n=4578) reported that women who were unable to attend antenatal classes were more likely to worry about not knowing when labour would start (Henderson and Redshaw, 2017). This is also consistent with the findings of a Danish randomised controlled trial (n=1766), which found that antenatal education increased women's confidence in their ability to cope with labour (Brixval et al, 2016).
Differentiating between early and active labour
Differentiating between early and active labour is difficult and can create a ‘negative loop’ where women come to delivery suites too early (Miller et al, 2020). This is particularly true for the first-time mothers. Additionally, multiparous women often labour more quickly than nulliparous women (Ashwal et al, 2020).
Differentiating between early and active labour is crucial to ensure admission takes place at the appropriate time. However, it is not always possible to determine the exact onset of labour based solely on the strength of contractions. Progress of labour is dependent on a combination of factors including the advancement of contraction pattern and cervical dilatation, which can only be obtained by conducting a physical assessment and evaluation, for example, a vaginal examination (Jackson et al, 2003). Therefore, it can be difficult for midwives to provide appropriate information on when to present to a delivery suite or labour room during antenatal education.
Importance of clear communication and advice
Lack of clarity or vague responses from healthcare providers can increase women's concerns or anxiety. In Brunei, pregnant women are advised during antenatal visits to present to the delivery suite upon feeling any pain. However, women are not made aware of the differences between contraction pain and Braxton Hicks, which can cause confusion (Gross et al, 2009). A systematic review of 62 English, French and German studies conclusively reported discrepancies in defining onset of labour and the unpredictable nature of labour progress (Raines and Cooper, 2021).
Analysis and discussion
In clinical practice, the latent phase is typically the longest phase of labour and has been described as ‘a period of time when there are painful contractions, and there is some cervical change, including cervical dilatation up to 4cm’ (National Institute for Health and Care Excellence, 2017). Kobayashi et al (2017) investigated how women perceived the onset of labour based on signs and symptoms such as contraction pain, rupture of amniotic membranes, blood, vaginal discharge, changes in sleeping patterns and emotional instability. Women reported uncertainty and anxiety about presenting at the hospital too early or too late and a need for validation to overcome this fear of the unknown, which significantly heightened their anxiety (Kobayashi et al, 2017). Detailed and accurate anticipatory guidance about what to expect during late pregnancy and early labour should begin during antenatal care.
A qualitative study conducted in Canada (n=15) discovered that discomfort, uncertainty and anxiety heavily influenced a woman's decision to seek care during the latent phase of labour (Auxier, 2017). In the UK, guidelines in clinical practice clearly outline that early labour assessment should include triaging via phone and face-to-face labour assessment for all low-risk nulliparous women in their homes or their planned birth places (National Institute for Health and Care Excellence, 2017). Additionally, the WHO (2018) recommends that low-risk pregnant women presenting in spontaneous labour should delay admission to the labour ward at least until the first stage of labour. However, this should only be undertaken if comprehensive assessments have been done to answer any questions and uncertainties related to the effectiveness, acceptability and feasibility of interventions or options during childbirth (WHO, 2018). If labour progresses more quickly than expected, delayed admission may result in more harm than good. The baby might be born before the mother arrives at the hospital, increasing the risk of maternal and neonatal complications.
The relationship between early admission and subsequent medical interventions, such as caesarean section, augmentation of labour and epidural analgesia, means that midwives usually advise women to stay at home as long as it is appropriate during latent phase or send women home as a result of unestablished labour. It is uncertain whether avoiding admission or being sent home during the latent phase will result in improved outcomes. This has not been thoroughly explored in randomised controlled trials, but has been highlighted in some observational research, including confusion, anger and resentment, as well as stress and feelings of being neglected among women and their partners (Jackson et al, 2003; Baxter, 2007; Rota et al, 2018; Miller et al, 2020).
Implications for midwifery/maternal nursing practice
Communication
Disseminating antenatal information is an evolving process, constantly changing to meet women's and their partners' needs and expectations (Cutajar et al, 2020). There has been considerable interest in recent years regarding the potential for sharing information with women through methods such as DVDs, evidence-based leaflets and posters. These methods should be fully utilised to enhance dissemination of antenatal information.
In some countries, maternity healthcare providers are not the only source of antenatal education for expectant women (Dunn et al, 2003). Additionally, information or experiences may be shared by mothers, sisters, friends and traditional midwives. However, sharing information through social environments can lead to confusion.
Midwives have demonstrated that although they ask women to describe or explain their signs and symptoms when assessing progress of labour, they assess progress chiefly by measuring the length, intensity, duration and regularity of contractions and how a woman reacts to the signs and symptoms mentioned (Hutchison et al, 2021). Effective communication is a crucial skill in the midwifery profession, as it enables midwives to work in partnership with women, especially when assessing progress of labour. Therefore, it is essential for midwives to improve their communication skills through training or refresher courses.
The authors recently conducted research in Brunei, which found that midwives reported conflicting information on when to come to the labour room being given by different midwives in the same clinic, midwives in different clinics or midwives in other maternity and child healthcare centres, although this research is currently unpublished. This means that the information provided on active labour may be inconsistent and non-standardised. It also highlights issues surrounding the lack of continuity in the way information is communicated. Additionally, information may not be reiterated regularly at subsequent antenatal visits.
The Royal College of Midwives (2018) state that the principles underpinning continuity of care contribute significantly to quality maternity care. In Brunei, continuity of a single carer may not be feasible as a result of staffing issues, but the continuity of a group of carers may be feasible to ensure that antenatal education is consistent.
Having a named midwife may ensure continuity of care, and thus, communication (McInnes et al, 2020). If this is not possible because of limited staffing, continuity of carer in team midwifery may benefit women, where team midwives ensure continuous communication.
Antenatal preparation
In Brunei, the maternal and child health handbook includes information about pregnancy and the first 5 years of a child's life (including appointments, immunisation history and growth record). Women are required to bring the handbook to every appointment or whenever they visit the clinic or hospital. The handbook also provides antenatal information that focuses on early care, nutritional information and common ailments and warning signs during pregnancy. However, an unpublished study of midwives in Brunei reported that a large number of pregnant women lack the initiative to use the handbook (Luta et al, 2021). Some women shared feeling insecurity and vulnerable and reported that hearing affirmations directly from healthcare providers helps in validating what they are experiencing.
Women should have adequate and appropriate knowledge on what to expect during pregnancy, childbirth and postnatally; therefore, antenatal education is highly emphasised. In Brunei, pregnant women are usually provided with national dietary guidelines, health talks and health screening, which are free-of-charge in all maternal and child health clinics nationwide (Aji et al, 2019). To ensure the effectiveness of disseminating information, social media platforms should be used to reach out to women.
Use of technology (mHealth application)
Cappelletti et al (2016) identified a number of apps created and published to help women measure the frequency and duration of their contractions. There are also devices that include wearable abdominal monitors that allow women to distinguish between contractions and abdominal cramps. Additionally, websites that women can access for more information on pregnancy and childbirth have grown enormously, which can include women's stories about their labour experience and personal blogs. These additional resources can help women prepare for labour and provide education to avoid women presenting too early to hospital.
Conclusions
Determining the appropriate time to attend a delivery suite is not an easy task for pregnant women. Providing education on how women can diagnose early labour is not easy because of confounding factors, such as websites that share personal experiences and other women giving advice to pregnant women. Antenatal education should contain information that allows women to determine the appropriate time to visit the delivery suite. Labour management procedures, protocols and pathways should always be shared and discussed with women and their partners throughout pregnancy. This will help to empower women and reduce anxiety and fear that can lead to early and inappropriate admission to the delivery suite. Further research is required to explore how issues related to women unnecessarily occupying beds because of inappropriate attendance at delivery suites can be resolved. This includes the feasibility of women undertaking self-management at home prior to the onset of active labour that later requires professional management at the delivery suite.
Key points
- Antenatal education, including information on the onset of active labour, is integral in facilitating a positive childbirth journey and is an important part of holistic antenatal care.
- Knowledge on onset of active labour and how it may deviate from normal develops confidence and empowers women and midwives in deciding on appropriate timing on when to attend delivery suites.
- There should be clear standard procedures for healthcare professionals, including midwives, that guide management of women in admission to delivery suites at an appropriate time.
CPD reflective questions
- Why is antenatal education important in preparing women and their partners, including in helping them determine the appropriate time to attend the delivery suite?
- What information should be included in antenatal education that will aid women in attending delivery suites at the appropriate time?
- Does your practice provide suitable information to pregnant women on when to attend the hospital?