Women use different terms to describe distress in relation to a poor childbirth experience. Whereas some women consider it as having been negative, others feel their birth was traumatic (Creedy et al, 2000; Hodnett, 2002; Soet et al, 2003; Ayers, 2004; Waldenstrom et al, 2004; Beck and Watson, 2010; Beck et al, 2011; Storksen et al, 2013). This can lead to adverse consequences, including post-traumatic stress disorder (PTSD) (Ayers, 1999; Creedy et al, 2000). Other poor consequences that have been recognised following a traumatic birth experience are poor maternal and infant bonding (Ayers et al, 2006), a reduction in breastfeeding rates (Beck and Watson, 2010) and fear of childbirth in future pregnancies (Storksen et al, 2013).
In the late 1990s, services were set up and women offered debriefing by a midwife after giving birth in the UK and other western countries. The broad aim was to reduce psychological trauma. While it was unclear what these services provided women, a critical meta-ethnographic review of women's experiences of postnatal debriefing found that it satisfied women's need to talk, be listened to, receive information and gain a greater understanding of their experience. It also helped women to have their birth experience validated (Baxter et al, 2014).
A Cochrane systematic review of debriefing set in the maternity context was undertaken in 2015 (Bastos et al, 2015). This included seven randomised control trials (RCT). The authors did not find clear evidence that debriefing either reduced or increased the risk of a woman developing psychological trauma during the postpartum period. This was put down to the poor quality of the evidence, the use of different interventions and heterogeneity between the studies (Bastos et al, 2015).
However, the findings from a study of an Australian RCT suggested benefits to interventions designed to provide additional midwifery support to women between four and six weeks after birth. Women valued additional support provided by midwives in this way.
Reflecting on their birth helped them to make sense of their individual situations (Fenwick et al, 2013). The emotional and psychological impact of labour and birth on individual women was highlighted in the quantitative findings from a mixed methods research (MMR) study to investigate reasons why some women choose to attend or not to attend a birth reflections service (Baxter, 2019). This study identified that women with moderate or high post-traumatic stress (PTS) symptoms were more likely to wish to discuss their birth, consider it as negative and were less satisfied with care from staff during the birth.
Hodnett (2002) undertook a review to summarise what is known about satisfaction with childbirth, with particular attention to the roles of pain and pain relief. She concluded that the influences of pain, pain relief, and intrapartum medical interventions on subsequent satisfaction were found to be less strong than the influences of the attitudes and behaviours (Hodnett, 2002). Waldenstrom and colleagues (2004) in a longitudinal cohort study of 2 541 women in Sweden identified four key categories of risk for a negative birth experience: having an unexpected medical problem, such as an emergency caesarean section or augmentation in labour; factors from a woman's social life, such as unwanted pregnancy or lack of partner support; the woman's feelings during her labour (eg pain, lack of control); and the care a woman was given (eg lack of support in labour, administration of pain relief).
They concluded a lack of support from caregivers, lack of control and not being involved in decision-making increased the risk of a negative birth experience. This finding of a consistent effect of staff attitude and behaviour on maternal satisfaction with childbirth compared with medical interventions is also evident in the findings from a study on fear of childbirth in Norway (Storksen et al, 2013). These authors identified that 117 women (8.6%) from their sample of 1 357 subjectively rated their previous birth experience as negative. Perceiving their previous birth experience to have been negative was much stronger than the association between previous obstetric complications and fear of childbirth (Storksen et al, 2013).
There is also a need to understand further what it is about a woman's birth experience that causes her to view it in a negative light or experience traumatic feelings in the first place. It is clear from the work of Waldenstrom and colleagues (2004) described above that staff and other carers can influence a woman's experience of birth. A fuller understanding is required of what it is about the interaction between some staff and women which leaves them with negative and traumatic feelings towards their birth. It is possible there are other factors relating to the birth experience that women might also reveal through the use of a qualitative approach. Such detailed information is lacking from the quantitative studies in this area. This paper therefore presents qualitative findings from the wider MMR study (Baxter, 2017). These consider in greater depth women's emotions following birth and how they may be linked with the birth process.
Aims
The findings presented here stem from part of a wider MMR study on the topic of postnatal debriefing. The main study set out to determine the reasons why certain groups of women accessed (or did not use) a postnatal debriefing service and to provide a rich description of their perception of the service. The MMR study also explored women's feelings following birth. The findings presented in this paper relate to the latter aspect of the wider MMR study, which explored reasons why some women may leave the birth experience with emotional distress.
Methods
The MMR study used an explanatory sequential design in which different data were collected on the same topic. There were two distinct phases: quantitative followed by qualitative (Creswell and Plano Clark, 2011). A quantitative survey was first conducted to determine women's need to talk following birth and their understanding about what a birth reflections-type service is. Sequential to this data collection, qualitative interviews explored women's experiences of being in labour and giving birth, and whether or not they needed to talk about this afterwards. It also explored their experiences of a birth reflections service and their feelings following birth.
Qualitative research is an interpretative approach concerned with the meaning people place on life in general, including beliefs and values (Snape and Spencer, 2003). Qualitative data emphasises people's experiences. A descriptive qualitative approach was undertaken (Polit and Beck, 2010). Data were generated through the use of individual interviews whereby women's personal perspectives were mentally reprocessed and verbally recounted (Ritchie, 2003). A total of 16 semi-structured, qualitative interviews were undertaken.
Recruitment
The main sample was obtained from the quantitative strand of the wider MMR study mentioned above. The survey was administered to 447 women following birth and returned by 170 respondents (Baxter, 2019). Women were asked to provide their contact details if they were willing to be interviewed. A simple randomisation process was used to select 12 of the 72 women who agreed to be contacted. The original plan was to recruit 10 women who had attended the Birth Reflections service and 10 women who had not attended, from among the survey respondents. The rationale for this was based on theoretical sampling and estimates of numbers likely to achieve data saturation.
However, few of the survey respondents had attended the Birth Reflections service so a decision was taken to increase this sample from the clinic lists. One woman was selected, by the administrator of the service, who was independent of the study, for each of the four months between April and July 2013. Four women were contacted in this way and all agreed to take part in the study. The author was then able to contact them by telephone and make further arrangements. The whole recruitment process resulted in a sample of 16 women, four of whom had attended the Birth Reflections service.
Procedures
All but one of the women chose to be interviewed at home. The timing of the interview was between 8–17 months in relation to the birth experience for the women in the main sample and up to three years postpartum for those who had attended the Birth Reflections service. It was considered that the use of semi-structured interviews would provide greater flexibility: during interviews, non-verbal behaviours may reflect a lack of understanding of a question and so wording can be altered to help comprehension and engagement (Barriball and While, 1994). The sensitive nature of the topic area dictated that the interviews should be conducted on a one-to-one basis and not in group discussions. It was anticipated that women would not want to open up in a group.
Prior to commencing the interviews, all the women were given an information sheet about the study and time to read this through. They were subsequently asked if they had any questions and the interviewer (author) reminded them that they were participating in a voluntary capacity and were free to withdraw at any time. Written consent was taken.
An interview guide was used to ensure consistency of questions. All information provided in the interviews was treated in the strictest confidence. The interviews focused on the informants' experiences and views about the need (or not) to attend a birth reflections-type service. There was also discussion about the birth experience more generally and the participants were invited to tell the story of their birth.
Analysis
A total of 16 semi-structured, qualitative interviews were conducted as part of a wider MMR study (Baxter, 2017). The interviews were audio-recorded and transcribed. Thematic analysis was undertaken, using the process described by Braun and Clarke (2006). The author started the process by familiarising herself with the raw data. All the transcripts were read through on many occasions and codes given to small pieces of text ie sentences, phrases, paragraphs.
These were entered directly onto the printed transcripts in the margins. This was followed by the identification and review of possible themes that emerged from the codes and the consequent confirmation of themes. In this way, categories that recurred in data from other participants were merged under an umbrella of themes. Miles and Huberman (1994) refer to this process as ‘pattern coding’. The author's academic supervisor reviewed a selection of the transcripts and the coding process, and confirmed agreement and consistency of themes.
Findings
Some 16 women were recruited for semi-structured, in-depth interviews. Of those, 12 were identified through the survey and four through the Birth Reflections service as discussed above. Further details of these women are shown in Table 1.
| Participant number | Previous births | Method of birth | Age (years) | Attended Birth Reflections service |
|---|---|---|---|---|
| 1 | 0 | Forceps | 35–39 | No |
| 2 | 0 | Emergency c-section | 30–34 | No |
| 3 | 0 | Ventouse | 20–24 | No |
| 4 | 1 | Normal vaginal | 25–29 | No |
| 5 | 0 | Forceps | 30–34 | No |
| 6 | 1 | Normal vaginal | 35–39 | No |
| 7 | 1 | Normal vaginal | 30–34 | No |
| 8 | 0 | Normal vaginal | 30–34 | No |
| 9 | 1 | Normal vaginal | 30–34 | No |
| 10 | 1 | Normal vaginal | 30–34 | No |
| 11 | 1 | Elective c-section | 35–39 | No |
| 12 | 3 | Normal vaginal | 35–39 | No |
| 13 | 1 | Emergency c-section | * | Yes |
| 14 | 1 | Forceps | * | Yes |
| 15 | 1 | Forceps | * | Yes |
| 16 | 1 | Forceps | * | Yes |
The findings reported in this paper all relate to women's emotions linked to the birth process. Three themes were identified. These are described below under three separate headings: ‘giving birth as traumatic/horrific’, ‘lasting emotions linked to the birth process’ and ‘the impact of the health professional on women's experiences of giving birth’.
These are three of five themes from the qualitative strand of the MMR study. They all relate to women's subjective experience of emotional distress. The other two themes refer to other objectives from the wider MMR study. These were about women's reasons for wanting to talk to a midwife about their birth experience postnatally: ‘making sense through the blur’ and ‘the need to attend a Birth Reflections-type service’. These are discussed elsewhere (Baxter, 2017).
Giving birth as traumatic/horrific
‘…if you'd asked me a couple of months ago, I would have said, “I'll never do it again, it was most horrific”.’
Approximately half of women in the interviews used the words ‘traumatic’ or ‘horrific’ to describe their experiences of giving birth. This was more common among women giving birth for the first time. It is likely that the first birth is more difficult for women and they do not know what is normal or what to expect. Some felt shocked by it. This theme is further broken down into subthemes which illuminate reasons why some women experience the birth process as traumatic: ‘medical interventions’, ‘the pain of labour’, and ‘the effect of poor staff communication’.
Medical interventions
Traumatic feelings experienced by some of the women in the study appear to be related to the use of medical interventions. Induction of labour was mentioned by many of the participants as being a particularly difficult experience for them. When asked the direct question, ‘What made the birth experience horrific?’, one participant listed a series of procedures that were undertaken during her labour and birth:
‘I think from the three days of labour, to having the waters broken because [E] (baby's name) was so far down … pressing on the birth canal they had to push her up to break the waters … having the monitor on her head. Then to having second-degree tear and being stitched. Yeah, all I could think about up until a couple of months ago was the ring of fire and I can still sense the pain from that.’
Participant 1 also had a long induction of labour process. Looking back, she considered that her birth was horrific. As can be seen from the quote above, she alluded to a ‘ring of fire’ which seemed to reflect her lasting memory of pain and her baby moving through the birth canal. This participant also described having a fetal scalp electrode (FSE) placed on her baby's head to monitor the baby as being traumatic for her. There is a significant amount of other evidence in the data on this procedure being traumatic for women:
‘That took about 45 minutes to put on … I had my mum and my other half literally almost holding me down.’
Women also described vaginal examinations as being very painful:
‘They'd examined me god knows how many times. His head was turned the wrong way so they had to turn his head inside. The internal examinations, they're painful … I never quite realised how painful they were.’
Some participants also found the doctor coming into the room to be traumatic. This was a cause for concern for women and suggestive that something was wrong. Not knowing what was going on, and the doctor coming into the room unexpectedly, could lead to fearful thoughts and feelings. This can be seen in the below quote:
‘…that was the bit that was, for me, the most traumatic because, I think the doctor coming in makes you think, “Oh, something could be going wrong”.’
The pain of labour
For the women who expressed feelings of trauma, the pain of labour appears to be unlike any other pain and they felt it is not possible to prepare for it:
‘You can't prepare yourself for the pain, you've never experienced that sort of pain… and nobody can ever tell you what you thought it was going to be.’
According to one participant, the pain was so severe that she thought she was going to die. In addition, she remembered the situation being so distressing that her partner was crying:
‘I spoke to [D] (man's name) a little bit … I was sort of emotional because of what happened. I felt like I'd been beaten up and I couldn't really believe what had happened…’
It is clear that without appropriate support, the woman's pain in labour has a wider emotional impact.
The effect of poor staff communication
Some women described their birth experience as being traumatic following episodes of poor communication with staff in labour. One participant described how she went through her entire first labour experience (at a different centre in a large city) without communication with the midwife allocated to her and providing her care:
‘I was told off for screaming … I think the midwife was trying to make a joke but one of the few things she said to me was, “If you don't stop making such a fuss, I'll have to get a doctor”. This was at the end and I was having my stitches then, I think, and I wasn't screaming then but I burst into tears … because I was quite, I think, quite traumatised, just because no one was reassuring me at all … I couldn't tell whether my experience has been normal.’
Another participant remembered her first birth experience, which she described as being very painful long and traumatic. She had been told by staff on previous shifts that there was no clinical reason to undertake a c-section. At a later point, a different doctor came on duty and took over her care. Shortly after, this time, this woman had a caesarean section. At a later time, the second doctor informed her that she would never have given birth normally. As a consequence, she was left with worrying feelings that if the c-section had been performed at an earlier point, then her baby might not have contracted meningitis and needed to remain in hospital for 10 days following birth:
‘[D] (woman's partner) did and still does feel quite a bit of bitterness because [L] (baby's name) was poorly and it probably was as a direct result because he was so distressed when he was inside, they explained that meningitis is an infection of the brain but it can come from anywhere … if I would have been given a caesarean earlier, he may not have been poorly because he pooped twice within a 12-hour period.’
Lasting emotions linked to the birth process
This theme shows that some women are left with heightened emotions relating to the birth experience. It has three subthemes: ‘anger’, ‘fear of giving birth again’ and ‘living in an emotional bubble’.
Anger
As has been seen above, some women left the birth experience with angry feelings. They apportioned blame to the staff involved in their care and this was sometimes misplaced. The angry feelings prevented these women gaining a clear understanding of the reason for the unexpected poor outcome:
‘No, angry at the treatment from the hospital … angry at how I felt, the way I was treated while I was in labour and the birth itself. I felt like it had gone horribly wrong … I was very angry at the whole experience. In fact, I had counselling about it.’
After refusing to meet with staff at the maternity unit following her first birth experience, Participant 14 sought out a c-section when she became pregnant for the second time. Staff encouraged her to attend the Birth Reflections service at this time, which was two years later. It was at this session when she learnt her anger had been misdirected and her wound infection had not been caused by the doctor whom she blamed. It is of interest that this same woman went on to give birth naturally and this subsequent birth experience was positive.
Fear of giving birth again
All of the four women who had attended the Birth Reflections service expressed degrees of hesitation about becoming pregnant for a second time and having to face giving birth again. One woman rushed to get pregnant again as she knew she needed to have another child at some point. Due to the negative and traumatic experience of her first birth, she wished to get the subsequent experience over with as soon as possible. The remaining three women also shared their fear of giving birth again:
‘So it was actually the experience with [J] (first child's name) that impacted on pregnancy with [E] (second baby's name) and whenever I was going to my community midwife appointments for some reason, inexplicably I would end up in tears because I was so terrified about giving birth again because of what had happened the first time ‘round…’
Another woman, left feeling like she was ‘in an emotional bubble’, feared giving birth again following her first birth experience. She said that this was because she had been moved to theatre from her labour room during an emergency when the staff had been unable to hear her baby's heartbeat. This woman thought her baby was dead. In addition, she was taken into an operating theatre, which brought back personal memories of the death of her sister at the age of 21 years.
Living in an emotional bubble
Some participants described being in an emotional bubble. They felt distanced from others and not like other mothers. This remained for many months following birth and had an effect on the subsequent pregnancy. This could lead to anxiety and fear of giving birth again, as mentioned above. It seemed that the midwife at the Birth Reflections service was not always appropriately equipped to give psychological support:
‘It's good to be able to talk through something but I don't think that the midwives are properly trained in that emotional, psychological element, the counselling element … talking through a traumatic experience, getting answers is great…’
Another woman also felt the need for more emotional support. She did not engage with her baby and felt that she was merely existing for the first few months after her baby was born. It took five months for her to seek help from the midwives at the Birth Reflections service after being referred there by her health visitor.
Impact of the health professional on women's experiences of giving birth
Staff members were found to play a key role in a woman's experience of labour and birth. Five key subthemes are listed under this theme: ‘trust in staff’, ‘the need for sensitive communication’, ‘relationships with staff’, ‘supported by staff’ and ‘the need for information’.
Trust in staff
It was clear from the data that the women placed their trust in the staff who provided care to them. Trust seems to be displayed in many different ways. Some women mentioned the skills of the midwives looking after them. One woman highlighted the midwife's thoroughness at suturing, following the birth:
‘It felt like I was there for a long time but I think she was just very thorough.’
The need for more sensitive communication
Whereas there were many examples of superlatives in the data describing midwives (eg ‘lovely’, ‘brilliant’, ‘amazing’, ‘fantastic’), some women were upset by their encounter with midwives and doctors. This led women to feel less confident in the staff providing care and consequently feeling less supported. Some women reported feeling that they were not being listened to by the staff providing care. Being told to go home again following admission with painful contractions is one example of women feeling that staff were not listening to them. Women also spoke of not being kept in the loop with what was happening during their labour:
‘…and I actually said, “Are you serious? Why are you talking about a caesarean?” And they were like, stopped. So I was looking at the boys … my son's dad going, “Why are they talking about caesarean? I'm not even in labour,” and nobody had given me any indication that there was a massive problem so that annoyed me quite a lot. The fact that that conversation was had directly in front of me as if I wasn't there.’
Relationships with staff
Some participants spoke of a relationship between themselves and the midwife providing care. There is evidence in the data that women were empathetic towards the midwife caring for them. This is seen below in a situation where a woman was left feeling upset by the midwife during her first birth experience at a different hospital in a large city:
‘…I imagine that it must be quite hard sometimes, particularly if you are working in a busy hospital and you've got so many patients … you almost must become anesthetised to the role sometimes…’
Supported by staff
There were many comments in the data of women feeling supported by staff. This showed examples of what supportive care meant to them. These included the continuing presence of the midwife and the provision of comfort measures. On occasions, women did not feel supported by the staff providing care:
‘…she was really stern, she was an older lady and I was saying, “Help me,” when I was going through the contractions … but she said that I wasn't in pain, when I was in so much pain.’
This conveys the effect on women's feelings when having their perceptions dismissed. Some women also reported the need for staff to listen to them and involve them in decisions. One woman compared her first birth experience at another hospital where she was given instructions during her labour and birth. At the second unit, suggestions were offered for her to accept or decline as she chose.
Women seemed to reach the conclusion that birth is usually very difficult, but the outcome can be positive with the right support from staff. This is illustrated with the quote below from a woman who had a difficult first birth experience but who felt supported much more effectively by staff during her second birth:
‘…I did send a “thank you” card but the midwife who dealt with me when I was having her was just fantastic. I felt like she read my birth plan and she reassured me and … listened to me and took our concerns seriously … she was fantastic and afterwards, if I am honest, I think it all boils down to the people around you. I think it does. That made a difference to our first and second, awful labours aside.’
The need for information
The participants also identified the importance of being provided with regular, clear information from staff. Being constantly updated about what was happening led one woman who, despite having had a traumatic birth experience due to severe pre-eclampsia, rating her birth as positive:
‘Because both our health was at risk and I understood that. I always understood it because as I said, they were so … every single person who came in, “This is what's going on with you, this is what we are doing and this is why,” —so good.’
It is clear that women require continuous information during labour and birth, and also postnatally. Even though in emergency situations, this might be challenging, a few well-chosen words could make all the difference to a woman's experience.
Discussion
The findings described above confirm that some women leave their birth experience with ongoing negative emotions. This study also reveals that some women leave the hospital after giving birth with feelings of anger, fear of giving birth again, feeling distanced from others and not feeling like other mothers (‘living in an emotional bubble’).
The analysis identified possible reasons why some women may leave the birth experience with emotional distress. Approximately half of the women interviewed identified themselves as having had a traumatic birth experience, alluding to physical and/or emotional impact. This study has highlighted how midwives can affect a woman's birth experience. From this study, it seems that trauma relating to the birth event may be mediated by professional behaviours and how supportive they are. The findings of the present study also identified poor staff communication as contributing to women's perceptions of birth as being traumatic.
Other studies highlight how the actions or inactions of staff can result in care being experienced as dehumanising, disrespectful or uncaring (Elmir et al, 2010; McKenzie-McHarg et al, 2015). In the study by Creedy et al (2000) of acute trauma symptoms in childbirth, women who reported care as being poor were more likely to be dissatisfied with the decisions made by staff about their treatment; to perceive that they were not consulted or respected and to report procedures as painful. Wijma et al (1997) in their cross-sectional study in Sweden, of prevalence of PTSD after childbirth and women's cognitive appraisal of the childbirth experience, also identified an association between contact with staff and PTSD (Wijma et al, 1997).
Similarly, in the UK, Czarnocka and Slade (2000) found that perceptions of a low level of support from staff by women were associated with experiences of PTSD. The findings of the current study also concurred with a qualitative meta-synthesis of women's perceptions and experiences of a traumatic birth. In this study, a theme ‘to be treated humanely’ was formulated which included mistreatment from health professionals and distress when large numbers of staff came into the room without prior explanation (Elmir et al, 2010).
An example of how poor communication with staff may lead some women to perceive their birth as traumatic is not being kept informed or knowing what is happening (eg something happening unexpectedly or thinking that something has gone wrong when a doctor suddenly appears in the labour room). The role communication plays is also important in relation to pain. It seems that it is not as simple as pain per se, but about the level of informational or emotional support for women to cope with it.
If this is not forthcoming, some women may alternatively perceive the pain as traumatising. The supportive presence of a midwife who provides information to a woman in labour, about what is happening and how her body is functioning, can assist her to work through a difficult time period and successfully progress to the second stage of labour (Mander, 2002). Good quality support provided through continuity of care can help women cope with pain. Hodnett and colleagues (2013) in a systematic review concluded that women who experienced midwifery continuity of care were less likely to have had any pharmacological analgesia and regional analgesia.
Anger relating to their birth experience was another emotion described by some of the women in this study. Ayers (2007) highlighted how anger has not been widely examined during childbirth and how, during or following the birth experience, anger can be a possible sign of PTSD. These women leave the hospital environment feeling unhappy and with unresolved issues. These feelings are often directed towards the care providers themselves.
It seems that it is not only women who experience emergency complications during labour and birth who find labour and birth to be difficult. Women without apparent complications also perceived birth as being difficult. Indeed, some perceived it as being traumatic. Going without effective support at this critical time, as well as leading to dissatisfaction with the overall birth experience, also risks increasing undesirable, emotional sequelae among women.
A range of studies have identified that women who have negative perceptions of their birth experiences risk developing a fear of childbirth in the future (such as Beck and Watson, 2010; Thomson and Downe, 2010; Storksen et al, 2013; Thomson and Downe, 2016). In the current study, all four women who had attended the Birth Reflections service experienced this phenomenon. In addition, there were others who had not attended the service who also said this was an issue for them. This fear was often an after effect of a difficult birth experience. This might be due to the behaviour of staff, who had failed to provide appropriate support, or as a direct effect following what had been perceived by the woman as a traumatic incident.
There is a need to take measures to prevent women leaving the birth experience with unmet emotional needs. There is the possibility that with improved communication between the staff providing care and women that the intensity of negative feelings might be reduced or prevented. There is the risk that some women spend many months following birth ‘just existing’ and seeing other women with their new babies behaving differently from themselves. They feel distanced from their baby during this time. This situation also highlights the case for more continuity of care. In these models, women feel more supported. In addition, working in this way is beneficial for midwives (McCourt and Stevens, 2009). Continuity of care is now prioritised in UK maternity policy (NHS England, 2016) and in global guidelines for quality maternal and newborn care (Renfrew et al, 2014).
Strengths and limitations
Rich, qualitative data were generated from the in-depth interviews during which the participants were able to provide information about how they perceived their experiences of labour and birth. The result is a clear picture of what was important for these women during this time.
However, it needs to be considered that there was a range in time gap since the birth experience among the women who participated in the qualitative interviews. It is possible that these women's memories of what happened to them changed. The literature suggests that women are able to vividly and accurately recall their birth experiences after many years (eg Simkin, 1992). This seems to have applied to the women in this study who provided clear accounts of their one or two birth experiences during the interviews. There is learning to be shared from this study. However, it was exploratory in nature and took place at one hospital in England. Further work is therefore required to confirm that the findings are transferable to other settings.
Implications for practice and future research
The concept of emotional safety needs to be further explored to increase the evidence base in this area. The current study identified good examples of exemplary support provided to women by midwives. However, there were also examples of poor staff interaction with women which led to ineffective communication. For some women, this resulted in a negative birth experience as well as the perception that the birth was traumatic.
The effect of the professional care provider on a woman's overall labour and birth experience is very powerful. There appears to be a need for all staff to be supported to provide optimal relational care to women. Reviewing midwives' skills in general may also help to identify other skills, including interpersonal skills. Maternity services and education providers need to ensure optimal training in communication skills for all healthcare professionals who provide care to women during labour and birth.
The ability to listen to women and recognise their perceptions as normal for them will be paramount. This would take place both through undergraduate midwifery programmes and continued in continuing professional development (CPD) activities. Improving communication skills in this way will enhance relationships with women in our care. This should reduce rates of distress postnatally and the consequent need to attend postnatal debriefing services. However, these changes will not happen overnight and there will be the continued need for postnatal listening services.
Conclusion
It is clear that some women are unhappy and disappointed in relation to their birth experience. This study has highlighted the importance of the support provided by the individual care professional as a key factor associated with a negative birth experience from the women's perspective.
This finding is supported by quantitative studies and in a range of contexts internationally (Creedy et al, 2000; Waldenstrom et al, 2004; Sawyer et al, 2013; McKenzie-McHarg et al, 2015). Effective support during labour and birth is essential to ensure women have good experiences. This also reduces the risk of feelings of trauma and negativity which can in turn lead to secondary fear of childbirth and poor psychological wellbeing. This study provides evidence from women's subjective experience to support this view.