Midwifery students and routine discussion of birth experience in the early postnatal period in hospital

Background

Giving birth is generally seen as a positive, life changing event within Western culture. However, birth can also be a distressing and traumatic experience for some women. Psychological trauma, experienced during childbirth, may present post-birth as anxiety, mental health issues, and a reduced ability to build relationships with others (Fryer and Weaver, 2014; Bastos et al, 2015). It has become increasingly acknowledged that a woman's experience of childbirth can adversely affect her transition to parenthood (Daley-McCoy et al, 2015). Psychological trauma during childbirth may also affect the mother's ability to bond and care for her infant, reduce breastfeeding rates and may increase her risk of postnatal depression (Bell and Andersson, 2016).

Women's future pregnancy planning may be affected by fear, and may also present as voluntary infertility and maternal requests for caesarean sections (Garthus-Niegel et al, 2014). Furthermore, psychological trauma experienced during labour and birth may cause post traumatic stress disorder (PTSD), which is thought to affect between 3-9% of women (Beck et al, 2011; Grekin and O'Hara, 2014). A diagnosis of PTSD resulting from childbirth-related psychological trauma comprises a range of possible symptoms, including nightmares, flashbacks, persistent avoidance of reminders and hyperarousal (Peeler et al, 2013). Psychological trauma arising from childbirth has also been linked to postnatal depression (Bell and Andersson, 2016), which is currently thought to affect up to 6% of women in the postnatal period (Furuta et al, 2016).

In attempting to reduce psychological symptoms of women in the postnatal period, the midwifery practice of ‘debriefing’ following birth was developed in the 1990s, and was based on the counselling practice of critical incident debriefing (Lavender and Walkinshaw, 1998). However, research has since revealed that there is no evidence to support or reject the use of psychological debriefing for the prevention of psychological trauma following childbirth (Bastos et al, 2015). As a result of this recent finding, routine discussion of the birth experience is not always offered to women in the postnatal period. Current research advocates for a post-partum talk to allow the woman to express her emotional experience (Baxter et al, 2014; Dahlberg et al, 2016), suggesting an informal, routine discussion of the birth experience with a midwife (National Institute for Health and Care Excellence (NICE), 2014).

Many developed countries, including the UK, Australia, the US and many in Europe, already embrace discussion of the birth experience into midwifery practice. However, at the time this study was conducted there was currently no research available on the practice of the routine informal discussion of the birth experience being taught to midwifery students, or any literature that assesses the knowledge, experiences and attitudes of midwifery students undertaking routine postnatal birth discussions with women.

Setting

This study was conducted in Western Australia. Maternity care is mainly offered through a medical model at both public and private hospitals in metropolitan Western Australia, although a small number of midwifery models of continuity of care are also available. Within the public maternity care system, the average length of postnatal stay is 24 hours for a vaginal birth and 72 hours for a caesarean birth, with midwifery care provided within the home for up to 5 days by a designated midwife from the Visiting Midwifery Service (VMS).

Within the private maternity care setting length of stay can be up to 5 days without community care provided. The majority of midwifery students gain their clinical experience in hospital settings with a predominantly medical model of care. There were 35 135 live births recorded in Western Australia in 2015 (Australian Bureau of Statistics, 2015), with a high rate of obstetric intervention. The caesarean rate of 57% at one private hospital is amongst the highest in the country, with the rate of inductions of labour being equivalent to other Australian states at 29% (Owen, 2015).

Aim

The aim of this study was to explore midwifery students' knowledge and experiences of the routine discussion of the birth experience in the postnatal period. In caring for women and their families holistically during the postnatal period, midwives need to have the skills and knowledge to meet both the physical and emotional needs of women.

It is important for midwifery students to gain appropriate knowledge and skills, so they can become skilled and safe practitioners, as well as become a valuable part of the midwifery workforce. This study adds to the body of knowledge associated with how midwifery students experience clinical practice, and also provides data on postnatal care. This may be used to inform midwifery educational programmes, ensuring universities are able to meet preregistration midwifery standards.

Methodology

An exploratory descriptive design using a qualitative approach was deemed the most appropriate methodology for this Masters by coursework study, as it aimed to explore the experiences and feelings of midwifery students. The exploratory descriptive approach collects narrative data from small sample populations, as participants' words are used to describe the phenomena under observation (Fenwick et al, 2013), and is ideal if limited information exists on a topic (Grove et al, 2012).

Methods

This study was conducted using a mixed method approach in order to gain knowledge and understanding regarding midwifery students' experiences of the routine discussion of the birth experience in the postnatal period.

Participant sampling

The participants were selected using convenience sampling, which has some limitations in that it can make it more difficult to generalise findings (Peterson and Merunka, 2014). A total of 36 postgraduate midwifery students were invited to participate. The postgraduate midwifery students were registered nurses enrolled on a midwifery course, and completing the clinical midwifery component of the course in the paid employment model at one hospital only. The midwifery students were employed as student midwives 3 days per week.

Participant recruitment

Information about the research project, with a link to the online survey, was circulated to the postgraduate midwifery students through an online social media site, which was a closed group site with only postgraduate students enrolled on the midwifery course as members. Recruitment ceased approximately 4 weeks after being distributed, and one reminder email was sent to all participants prior to the study closing.

Data collection

Data were collected via an anonymous online survey, using quantitative and qualitative questions. This study was part of the requirements for a Masters by coursework degree, and the self-administered online survey used 15 questions, including Likert-scale questions to obtain demographic information. Text boxes allowed for answers to qualitative questions, which provided an opportunity for participants to provide additional information about their experiences of the routine discussion of the birth experience in the postnatal period. It was also an opportunity for students to express any concerns they had about undertaking or observing routine discussions regarding the birth experience. The online survey was also seen as a cost and time effective approach.

Data analysis

Quantitative data were analysed via the Qualtrics software, and the qualitative data were entered into an Excel spreadsheet and analysed by thematic analysis to establish common themes regarding the participants' experiences and responses.

Ethical considerations

This study was conducted as part of a Masters by coursework, and ethical approval was granted by the University ethics committee. No personal identification was requested in the survey in order to protect participants' anonymity. The survey was implemented using Qualtrics software, which provided easy access for participants at a convenient time. Potential participants were guaranteed anonymity and confidentiality, and participants were made aware that if they clicked onto the link and completed the online survey, then consent was implied. No incentives were offered, and the participants were reminded that there were no penalties if they did not wish to participate.

Findings

A total of 20 midwifery students responded to the survey from a sample of 36 potential respondents, giving a response rate of 55.5%. Of the respondents, 5 were employed as midwifery students in private hospitals, and 15 respondents were employed in public hospitals. No further demographics were collected, so as to maintain anonymity of the participants.

Some 10 (50%) midwifery students stated that they felt they had not received adequate training and education in order to lead a discussion with women about their birth experience. Additionally, 14 (70%) students indicated that they felt they required further knowledge and education to increase levels of confidence and ability in leading a birth discussion with a woman. Many of the students reported giving women an opportunity to talk about their experiences in the postnatal area, and reported facilitating this by using their communication skills, which some reported to have been acquired by life experience and previous nursing training.

In addition, 17 (85%) students indicated that they felt they needed further experience to enable them to adequately lead discussions on the birth experience with women, and 12 (60%) students specified that they would like to observe a midwife discussing a birth experience with a woman in the postnatal period. The students also commented on leading birth discussions as being ‘stressful’, ‘afraid of opening a can of worms' and ‘worried about adding to trauma’.

The midwifery students were asked about their knowledge regarding psychological trauma attributed to birth experience. In all, 10 students (50%) stated that they did not have sufficient knowledge to recognise a woman undergoing psychological trauma. However, 10 students (50%) stated that they did have sufficient knowledge or felt they had some knowledge of symptoms of psychological trauma. The students discussed using their observation skills clinically to assess if a woman was behaving appropriately postnatally, and some students mentioned only being able to assess a woman if the signs of trauma were ‘visible’.

Signs of trauma that students identified were ‘lack of bonding’, ‘being withdrawn’, ‘not coping’, ‘tearful’, ‘not eating’ and ‘being detached’. Some midwifery students stated that they could ‘sense’ if something was ‘not right’ with a woman's mental health postnatally; however, none of the students discussed how to implement a plan of action. Several students did mention the use of the Edinburgh Postnatal Depression Scale (EPDS) to assist in the assessment of psychological trauma. Five (25%) students reported that they would like further education on the symptoms of perinatal mental illness.

Of the midwifery students, 13 (65%) had not observed a midwife leading a routine birth discussion in the postnatal period. In addition, students said they were confused about what a routine birth discussion was, and that if they carried out birth discussions with women, they were usually unsupervised. Midwifery students also reported that birth discussions in the postnatal period did not take place for all women, even though the birth discussion is reported to be part of the midwifery discharge checklist. The students cited time constraints, and lack of privacy due to family or friends present, as the primary reasons they thought the discussion of the birth experience did not occur in the postnatal ward.

Discussion

A birth discussion is a conversation that asks a woman about her birth experience, and previous studies have reported some confusion regarding the interchangeable use of the terms ‘birth discussion’ and ‘debriefing’ (Alexander, 1998; Baxter et al, 2014; Fryer and Weaver, 2014). A ‘debrief ’ consists of the use of the psychological intervention of critical incident debriefing and is used to reduce the psychological symptoms after a traumatic event (Bastos et al, 2015). It has been suggested that the term ‘debriefing’ is not appropriate for the routine practice of discussing a woman's birth experience, and should be replaced with the term ‘childbirth review’ instead (Skibniewski-Woods, 2011; Sheen and Slade, 2015). Perhaps clarification surrounding the term and content of discussions with women after childbirth requires consideration by midwifery educators and academic institutions.

Some of the midwifery students in this study stated that they were equipped with the communication skills to carry out birth discussions with women due their previous educational, clinical and life experiences. But there were others who expressed that they did not feel capable of leading this discussion. A previous study has reported similar findings, stating that midwifery students and midwives can feel nervous starting these conversations and suffer with a subsequent lack of confidence (Jones et al, 2011). Therefore, it may be useful to explore these issues with midwifery students in the classroom, using role-play to recognise the skills required and build confidence.

The midwifery students in this study reported that they felt they required further knowledge and education to increase their confidence in undertaking a discussion with a woman about her birth experience. This finding is consistent with a recent study that revealed how midwifery students had low levels of knowledge of mental health problems in the postnatal period, and minimal confidence in caring for women with mental health problems (Jarrett, 2015).

Caring for women with mental health issues—either existing or due to complications of pregnancy and birth—is central to the provision of safe and effective midwifery care (Royal College of Midwives, 2017; NICE, 2014). However, it should be considered normal for midwifery students to feel unconfident as beginner practitioners, who are still building their skills and knowledge. Furthermore, experienced registered midwives have also been reported as having knowledge deficits in the assessment of depressive symptoms during the postnatal period (Jones et al, 2011).

It has been recognised that there is often a lack of a structured approach to the assessment of emotional well-being in the postnatal period (Yelland et al, 2007), which may explain why midwifery students appear to struggle to gain the skills and confidence required to carry out routine birth discussions. It has been demonstrated in the findings from a recent study, that an implementation of an educational module of perinatal mental health increases midwifery students' knowledge and confidence in caring for women with mental health issues (Davies et al, 2016).

This study did not assess actual knowledge of the symptoms of perinatal mental illness, but some respondents did elaborate on what they thought the signs and symptoms included.

Routine discussion of the birth experience

The study highlighted that midwifery students reported that routine discussions of the birth experience did not take place for all women in their clinical placements. Reasons for this were reported to be lack of time, heavy workloads on postnatal wards, lack of continuity of care and the perceived low priority of psychological care in the postnatal period. Empirical research reports that women want to talk about their birth experiences and found discussions beneficial (Peeler et al, 2013; Bastos et al, 2015; Sheen and Slade, 2015). Furthermore, research suggests that the discussion of the birth experience in the postnatal period is an expected part of midwifery care (Dahlberg et al, 2016).

Currently, the provision of midwifery care in the postnatal area has been reported as being affected by heavy workloads and time constraints (Hunter et al, 2015), and these issues were also highlighted as important factors in hindering the routine discussion of the birth experience taking place in the early postnatal period by students in this study. Reduced length of hospital stay may also be a factor in the low uptake of routine birth discussions. The postnatal hospital stay has been reduced in most developed countries, thus reducing the time available to carry out assessments of woman and baby, education and documentation required (Bowers and Cheyne, 2016).

Western Australian maternity care is organised in a medical model of care with pockets of midwifery led continuity of care models. The midwifery students in this study worked within the medical model of care. However, they did as part of the requirements for midwifery registration, experience continuity of care with at least ten pregnant women. The students talked about how it was easier to discuss a routine birth experience if they had a built a relationship with the woman, and how they imagined it would be hard for a woman to open up about her fears and disappointments if she did not know and trust the midwife. In contrast to this finding, a recent study suggests that women who give birth without their planned care provider present are more likely to report a traumatic birth experience (Reynolds, 2016).

Conclusion

Women have increased emotional and psychological needs after childbirth, and midwifery students do aim to meet these needs in the postnatal period. This study has highlighted midwifery students' experiences and knowledge regarding routine discussions of the birth experience, and their concerns regarding a lack of training and education in this subject. Midwifery students believed they were capable of conducting routine birth discussions, and expressed a desire to meet the psychological needs of women after childbirth. Heavy workloads, lack of continuity of care and a perceived low priority of psychological care in the postnatal period on the postnatal wards were identified as factors impacting upon routine discussions of the childbirth experience. Further research is required to ascertain the effectiveness of the routine discussion of the birth experience in the early postnatal period, as currently minimal evidence exists.

Key Points