Midwives play an important role in the journey of women in labour, from conception to birth and beyond. It is acknowledged globally that midwives are critical care providers of pregnant women and are the main professionals on birth wards, providing healthcare education and information to mothers- and fathers-to-be (Gunnervik et al, 2010). As a result, one study in the UK emphasised that midwives and other health professionals should be conscious of how ‘their own bias influences women's choices' (Houghton, 2008). Furthermore, Green (2015) cited a number of sources indicating that women perceived the influence of midwives as a critical factor regarding their birth position choices. In another UK study, it was argued that women in high-income countries, contrary to expectations, did not necessarily have the freedom to choose when it came to birth place (Coxon et al, 2014). This situation is similar to middle-income countries, as confirmed by a recent study exploring the birth stories of South African women (Hastings-Tolsma et al, 2018). Hence, the role of the midwife in improving women's birth choices, such as their choice of mode of birth, needs to be further explored, especially in the context of women-centred care (Sengane, 2013). It has been argued that the lack of midwife involvement in such choices is a possible reason for the high number of caesarean section births (James et al, 2012), and that midwifery-led care leads to a greater possibility of mothers choosing a spontaneous vaginal birth (Soltani and Sandall, 2012). In terms of safety outcomes, there is evidence demonstrating that there is less likelihood of interventions when midwives are in charge of maternity care (Sandall et al, 2009). This study therefore sought to explore and describe how midwives saw their role in women's chosen mode of birth at South African public sector birthing units.
Women have a right to an informed choice regarding their mode of birth; however, they are sometimes led to make an inappropriate choice due to the contradictory opinions of attending health professionals (Josefsson et al, 2011). In the UK, Lewis (2007) found that poor communication and ineffective teamwork among multiprofessional team members were often the underlying causes of sub-standard care of women in labour. This meant that women lacked advice and information about suitable modes of birth with regards to how their labour was progressing, including the option for vaginal birth. A study in the US concerning women's birth choices found that midwives provided multiple options for birth and that the type of birth was continuously discussed during antenatal care (Regan and McElroy, 2013); however, women in the study also indicated that their physicians did not appear to be willing to share information about birth choices. This finding was supported by an Irish study (O'Hare and Fallon, 2013), where women in labour felt as though they were being ‘spoken at’ instead of being ‘communicated with’ by the doctors. However, nearly all the women reported that the midwives were good communicators and played a pivotal role in preparing them for childbirth (O'Hare and Fallon, 2013).
A major factor to ensuring a positive birth experience was having the full support of a midwife. In an Iranian study, Attarha et al (2016) concluded that when health professionals had effective communication skills, there were many benefits for the patients, such as reduced pain, anxiety, and guilt, an increased peace of mind, and a sense of cooperation from the medical team. Good interaction is key to improving health outcomes and eliminating the need for additional care, reducing hospital costs, litigation, improving patient-oriented care and patient satisfaction (Attarha et al, 2016).
Midwives are sometimes referred to as ‘agents of change’ and by the very nature of their profession have the ability to make a positive change in the lives of women, babies, families and communities, acting as an intermediary between the women and the healthcare institution (Birthrights, 2013). It was found that being a good advocate was based on respecting, implementing and upholding women's preferences and choices (Birthrights, 2013). The midwife needs to be available to the women in time of need, when, for example, having to make a decision regarding a caesarean section birth; however, being a change agent comes with its challenges, especially when the midwife is working with other health professionals (McCool et al, 2013).
There is little research exploring the midwife's perspective of their role in women's preferred mode of birth. This study focuses on the role of midwives in women's choices in public hospitals and midwife obstetric units in South Africa, a middle-income country.
Methods
A quantitative descriptive research design was used for this study (Gray et al, 2017). The research population included all the midwives who were working in labour wards in the Nelson Mandela Bay Municipality and Sarah Baartman districts, which are located in the western half of the Eastern Cape Province. The population was approximately 1800 midwives. Convenience sampling was used and sample of 288 midwives was obtained.
A structured questionnaire was developed to collect the data. The questionnaire was in English and consisted of four sections:
Ethical approval to conduct the research was obtained from an authorised higher education institution. Access to the hospitals and midwife obstetric units were sought through the provincial office, chief executive's office, and with the aid of the operational managers. Participants were informed of the objectives and methods of the study. Care was also taken to explain their rights to voluntary participation, privacy and confidentiality.
Findings
Biographical data
Of the 288 midwife participants, 8% (n=22) were men and 92% were women (n=266). The majority (n=172; 60%) were 35 years old and older. Junior midwives were in the majority with 53% (n=153) of the participants having less than 1 year's experience working in a labour ward. More than one-third of participants (n=99; 35%) had been working for more than 5 years. Nearly half of the midwives (n=134; 47%) had a 4-year comprehensive diploma qualification, while 31% (n=89) of the participants had a nursing degree qualification.
Midwives' role in mode of birth decisions
These results are shown in Table 1. A high percentage of midwives (74%, n=210) indicated that women in labour should be allowed to choose their preferred mode of birth. A minority of respondents (n=50; 18%) disagreed, with only 8% (n=22) neither agreeing nor disagreeing.
| Strongly disagree n (%) | Disagree n (%) | Neither n (%) | Agree n (%) | Strongly agree n(%) | Total n (%) | |
|---|---|---|---|---|---|---|
| Midwives should allow women in labour their choice of mode of birth | 13 (5) | 37 (13) | 22 (8) | 116 (41) | 94 (33) | 282 (100) |
| Midwives should seek informed consent for the mode of birth chosen by women in labour | 5 (2) | 34 (12) | 28 (10) | 119 (42) | 97 (34) | 283 (100) |
| Midwives should enhance women's choices through the use of sound midwifery judgement | 7 (3) | 16 (6) | 31 (11) | 135 (48) | 91 (33) | 280 (100) |
| Midwives should be the only practitioners negotiating mode of birth with women in labour | 73 (25) | 157 (55) | 24 (8) | 22 (8) | 11 (4) | 287 (100) |
| Only senior midwives should advise women in labour regarding mode of birth | 65 (23) | 156 (55) | 26 (9) | 27 (9) | 12 (4) | 286 (100) |
| Antenatal care clinic midwives should take responsibility for helping women to choose a mode of birth during pregnancy | 23 (8) | 88 (31) | 39 (14) | 93 (32) | 44 (15) | 287 (100) |
| Midwives should be directed by the cultural background of the woman in labour | 12 (4) | 55 (20) | 51 (18) | 110 (39) | 54 (19) | 282 (100) |
| Midwives hold the responsibility for facilitating women's preferred mode of birth in labour | 24 (8) | 77 (21) | 48 (17) | 101 (36) | 34 (12) | 284 (100) |
| Midwives should gain the trust of women seeking advice in labour | 0 (0) | 4 (1) | 10 (3) | 142 (49) | 132 (46) | 288 (100) |
| Midwives should communicate how a woman's pregnancy is progressing to ensure that their chosen mode of birth is appropriate | 0 (0) | 2 (1) | 17 (6) | 131 (46) | 136 (48) | 286 (100) |
| Midwives should communicate how a woman's labour is progressing to ensure that their chosen mode of birth is appropriate | 12 (4) | 33 (11) | 17 (6) | 112 (39) | 114 (40) | 288 (100) |
| Midwives should not involve themselves in the choices made by women in labour regarding mode of birth | 45 (16) | 107 (37) | 43 (15) | 70 (24) | 21 (7) | 286 (100) |
Overall, 76% (n=216) of the midwives felt that it was appropriate that midwives should seek informed consent for the mode of birth chosen by women in labour. This response was opposed by only 14% (n=39) of the midwives with just 10% (n=28) neither agreeing nor disagreeing with the statement.
Of the participants, 81% (n=226) agreed that midwives should enhance women's chosen mode of birth during labour through the use of sound midwifery judgement. A few (n=23; 9%) disagreed with the statement and 11% (n=31) neither agreed nor disagreed.
Just 12% (n=35) of the midwife participants felt that midwives should be the only practitioners negotiating mode of birth with women in labour. This perception was opposed by a majority 80% (n=160) of the midwives, while 8% (n=24) neither agreed nor disagreed.
A substantial percentage of midwives (n=221; 78%) disagreed with the statement that only senior midwives should advise women in labour regarding mode of birth. A few (n=39; 18%) agreed, while 9% (n=26) of the midwives neither agreed nor disagreed.
Regarding the statement that antenatal clinic midwives should take responsibility for helping women to choose a mode of birth during pregnancy, 47% (n=137) participants agreed, while 39% (n=111) disagreed. A small proportion (n=39; 14%) neither agreed nor disagreed.
A majority of participants (n=164; 58%) felt that midwives should be directed by the cultural background of the women in labour; however, nearly one-quarter of the participants (n=67; 24%) participants disagreed.
Nearly half (n=135; 48%) of participants agreed that midwives should take responsibility for facilitating women's preferred mode of birth in labour. However, nearly one-third of the participants (n=101; 35%) disagreed and 17% (n=48) neither agreed nor disagreed, suggesting a degree of confusion over midwives' understanding of their role in guiding women's choices during labour.
Of the participants, 95% (n=274) felt that midwives should gain the trust of women in labour who were seeking advice, and most (n=267; 94%) agreed that midwives should inform pregnant women of how their pregnancy was progressing, to help them to make appropriate choices. Similarly, 79% (n=226) of participants felt that midwives should inform women of how their labour was progressing to help them make appropriate decisions. Overall, 31% (n=91) of the participants felt that midwives should not involve themselves in the choices made by women in labour regarding mode of birth, while 53% (n=152) disagreed and 15% (n=42) neither agreed nor disagreed with the statement.
Discussion
A high percentage (74%) of midwives indicated that women in labour should be allowed to make their own choices regarding their mode of birth. According to Klein (2012), the increasing acceptance by health professionals of a woman's right to choose her mode of birth is based on the assumption that the woman is fully informed; however, a number of sources have demonstrated that the proportion of births attributed to patient initiation remains small (Klein, 2012). This argument is supported by a UK study that indicated a lack of informed choice among pregnant women (Thompson and Miller, 2014).
In this study, midwives understood the need to equip women to make an informed choice, as the majority felt that they should be involved in women's choices regarding the mode of birth. The results therefore suggest that midwives understood their responsibility towards women regarding their choice of birth. Indeed, despite the apparent lack of informed choice, midwives in this study were wholly in favour of women making their own decisions. Linked to this was the fact that a high percentage of midwives said that it was appropriate to seek consent from the women in labour regarding her choice of mode of birth. However, in a UK study, midwives reported that they often felt that the provision of informed consent was often restricted by time (Thompson, 2013), meaning that, despite midwives' good intentions, it is possible that keeping the women fully informed does not always happen in reality. In line with this statement, Shahid et al (2014) argued that women required full and accurate information in order to decide on a suitable mode of birth. Moreover, Mbye et al (2011) noted that providing appropriate information has been proven to help reduce anxiety, allaying fear and motivating women in labour to tolerate pain.
The majority of midwives in this study agreed that midwives should enhance the choice of women in labour through the use of sound midwifery judgement. Cook and Loomis (2012) stated that the knowledge of the midwife, whether based on experience or philosophy, played an important role in influencing the final birth plan. Indeed, pregnant and women in labour have been shown to rely on midwives who are able to skilfully assess them and identify the need for a higher level of care as soon as complications occur (Shahid et al, 2014). Furthermore, midwives play a critical role in advocating for women so as to ensure safe, adequate, immediate and cost effective care (Seboni et al, 2013; International Confederation of Midwives (ICM), 2018).
Most of the participants in this study said that midwives should not be the only practitioners negotiating the mode of birth with women in labour. Seboni et al (2013) emphasised the collaborative role of midwives with other health professionals for the sake of care and referral. The midwives in this study appeared to support this collaborative approach; however, this can be complicated by the frequent disrespect shown to midwives by other health professionals. In a global study of midwifery, the World Health Organization (WHO) found that 36% of midwife participants indicated that they experienced a lack of respect from senior medical staff (WHO, 2016).
There was a mixed response to the statement that antenatal care clinic midwives should take responsibility for helping women to choose a mode of birth during pregnancy. South Africa has a relatively high percentage (61.2%) of early bookings (within 20 weeks) for antenatal care (Massyn et al, 2016); however, the majority of these are inconsistent in their attendance. If the responsibility to assist women in deciding their preferred mode of birth were to lie with antenatal care clinic midwives alone, defaulters could go unadvised and may be pushed into a mode of birth that was not necessarily their choice. Klein (2012) therefore argues that it is unreasonable to expect health professionals to change the attitudinal environment of birth on their own.
Almost half the midwives indicated that midwives should take responsibility for helping women in labour to choose their mode of birth. As midwives are mainly trained in primary care while the doctors are trained for the benefit of medical care (Newnham, 2010), this implies that midwives have a crucial role to play in bridging the gap between natural and the technical contexts (Andrissi et al, 2015). Furthermore, midwives are specialists in low-risk care midwifery care (Klein, 2010), which in many high-income countries is restricted to certain healthcare settings (Fawsitt et al, 2017). Therefore, the degree of responsibility is largely restricted by the type of unit.
A majority of midwives felt that they should be directed by the cultural background of the woman in labour. The ICM emphasises the need to work with women and healthcare providers to overcome cultural practices that harm women and babies, with a focus on health promotion and disease prevention (ICM, 2013). Midwives have been shown to be more equipped to respond to their patients' sociocultural needs when they accept that culture and society influence the beliefs, values, attitudes and behaviour of their patients (Kneisl and Trigoboff, 2009).
The majority of midwives in this study felt that they should communicate the progress of pregnancy and labour to women to assist them with choosing their mode of birth. Writing in defence of a patient-centred care model, Maputle (2010) emphasised communication with the woman as key to the success of the birth outcome. It was also found that providing emotional support to the mother and having good communication and interpersonal skills were the most important aspects of quality midwifery care (Sengane, 2013).
Linked to the importance of communication and culture in midwifery care is the issue of trust. Bäckström et al (2016) found that women felt that the midwives were well educated and could therefore provide trustworthy and reliable information. In this study, almost all midwives indicated that they should seek to gain the trust of women who are seeking advice. It is therefore critical that midwives have the necessary interpersonal skills, which are important aspects of a trusting relationship between a midwife and the women in her care (Lundgren et al, 2009; Leap et al, 2010).
Conclusion
There are many commonalities between the South African midwives and their counterparts in high-income countries regarding mode of birth, as demonstrated by the literature. The majority of midwives in this study perceived themselves as the main role players in assisting women in labour to make an informed decision with regard to the mode of birth that would best suit their circumstances; however, there was a sense that collaboration with other health professionals was also essential. Hence, it is critical that perinatal meetings are attended by all members of the multiprofessional team including midwives, managers and doctors. Where patient incidents are discussed, the contributions of all members should be treated with equal value, and the importance of the role of the midwife should be acknowledged.
Furthermore, the midwives in this study agreed that the culture of woman should be considered when deciding on a mode of birth and therefore midwifery curricula should include aspects of cultural diversity. In addition, there was a need for clear communication between midwives and women, which is critical for building trusting relationships. The majority of midwives were clearly aware of their responsibility to assist women in choosing their mode of birth; however, in the context of women-centred care, further research is needed to explore the roles of the various health professionals in women's chosen mode of birth.