Pregnancy and childbirth are described as transitional phases or existential thresholds that childbearing women have to cross. These events are multifaceted experiences with many dimensions, unique for each woman, and still strongly influenced by their social context (Nilsson et al, 2018). Women's expectations and experiences of pregnancy and birth are both positive and negative in nature, involving feelings of happiness and belief in a good outcome but also worries, anxiety and fears (Dencker et al, 2018).
Many women feel empowered, strong and competent, as they encounter the challenges of labour and birth, and experience a sense of joy and accomplishment (Callister, 2004; Khajehei and Doherty, 2018). Enhanced maternal-child attachment has also been shown to be associated with a positive pregnancy and childbirth experience (Mutlu et al, 2015). In contrast, other women report negative birth experiences that can be disempowering and have adverse effects on a woman's self-esteem, confidence, self-efficacy and mental health (Khajehei and Doherty, 2017). These women describe themselves as failures and express feelings of anger, frustration, guilt, loss of control, incompetence and inadequacy (Hildingsson, 2015). Negative or traumatic perinatal experiences can also lead to subsequent fear of pregnancy and childbirth, untoward outcomes in their future pregnancies (Ryding et al, 2015) and an increase in the likelihood of not having another baby (Shorey et al, 2018).
Since the perception of the childbirth experience is greatly individualised, women's views about what constitutes positive and satisfying, or negative and unpleasant experiences differ. While they may have a positive experience with some aspects of their pregnancy and days immediately after birth, they may be dissatisfied with other aspects of their experience, reporting coexisting positive and negative feelings (Taheri et al, 2018).
There has been increasing interest in conducting research on women's experiences of pregnancy and childbirth. Results of some studies have shown that many variables affect women's perceptions and experiences of the perinatal period (Dencker et al, 2018; Taheri et al, 2018). Perceptions relating to support from caregivers and partners, shared decision-making, met and unmet needs, pain and pain relief, the mode of birth, and access to information are the most frequently reported factors that affect women's childbirth experiences (Bryanton et al, 2008; Jónsdóttir, 2009).
Most international studies have adopted a quantitative approach to report about perceptions of the childbirth experience (Chadwick et al, 2014; McKinnon et al, 2014; Stankovic, 2017). While these studies emphasise objective measurements, and statistical and numerical analysis of data, they fail to collect data based on the participants' own words and experience (Neuman, 2011). To fill the gap, qualitative studies have been introduced to reveal underlying ideas through analysing words and phrases. Unlike quantitative methodology, qualitative research does not involve analysis of numerical data. It is an approach involving the development of an in-depth narrative explanation of individuals' reported experiences (Willig, 2001) and encompasses collecting, analysing and interpreting data related to the concepts, experiences and behaviours of individuals (Anderson, 2010). This type of research methodology is possibly premature in an area in which authenticated theoretical frameworks are not yet entirely developed (Barrett et al, 2000; Morof et al, 2003; Klein et al, 2009).
Qualitative studies on perinatal women have collectively investigated women's experiences throughout pregnancy, labour and the immediate days after birth (Baker et al, 2005; Tondi and Moir-Bussy, 2015; Schneider, 2009). Despite several international qualitative studies on women's perceptions of the perinatal period, there are limited recent data from Australia. Thus, we conducted our qualitative study to obtain narratives about women's personal experiences of pregnancy, labour and the immediate days after birth. Our findings will provide a more in-depth understanding and a better description of women's personal experiences of the perinatal period.
Methods
Design and setting
This was a qualitative study conducted at the postpartum ward at Westmead Hospital in 2019.
Participants
Women were invited to participate in our study if they met the inclusion criteria:
Women were excluded from the study if they did not meet the inclusion criteria, received caseload midwifery care or did not speak English.
Procedure
After obtaining ethical approval, the researchers (who were not clinical staff and were not involved in providing routine care to the women) approached the women who had given birth at Westmead Hospital and introduced the study and its aim. The women were given a copy of the patient's information sheet and enough time to read it and ask questions. Those who were interested in participation and met the inclusion criteria signed the consent form. They then completed a one-on-one, in-depth interview with the researchers. The interviews were conducted in a private room in the postpartum ward of the hospital.
Semi-structured, in-depth interviews and field notes were used to collect data on women's experiences of pregnancy, labour, birth and the immediate days after birth. An interview template was designed for data collection (Table 1). More probing discussion was invited by saying, for example, ‘Please elaborate on that’ or ‘What do you mean by that?’. All interviews were audio-recorded in MP3 format with the participants' approval. Each interview lasted for approximately 45–60 minutes. The interviews were conducted over a two-month period from December 2018 to January 2019.
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Previous research has shown that data saturation occurs within the first 12 interviews, although the basic elements for meta-themes are present after as few as six interviews (Guest et al, 2006). Therefore, we started with recruiting seven women and then conducted thematic analysis of our data. Sampling continued until the emerging thematic structure appeared to be saturated after recruiting 11 participants. However, we continued recruiting more participants (to n=16) to ensure no further themes were discovered.
Data analysis
We analysed the data using the following process for thematic analysis (Colaizzi, 1978a; Colaizzi, 1978b). We read all participants' descriptions of their experiences of pregnancy, labour and after birth. The responses were reviewed, coded and assigned to major, broad categories, which were colour-coded. Next, we extracted important statements that related directly to participants' experiences at each stage. This helped us formulate definitions for these important statements. Then we categorised the formulated meanings into clusters of themes.
During this process, each reviewer performed an inductive analysis, from which the descriptive themes emerged to answer the research questions. Each reviewer first did this independently and then as a group. Through group discussions among the researchers, more analytical themes emerged. We repeated this cyclical process until the new themes were sufficiently described and all initial descriptive themes were explained. Our next step was to integrate our findings into a comprehensive description of the women's experiences of pregnancy, labour and after birth. The emergence of patterns during the previous steps resulted in a more sophisticated level of coding, which assisted in developing sub-themes and conclusions.
Findings
We interviewed 16 primiparous women during their postpartum hospital stay. Demographic characteristics of the women are shown in Table 2. We found that confidence was the overarching theme contributing to the women's experiences of pregnancy, labour and the immediate days after birth. This theme encompassed two main categories as positive experiences that aided in building confidence, and negative experiences that adversely affected confidence. We identified a total of five main themes and 15 sub-themes (Table 3).
| Characteristic | Frequency % (n=16) |
|---|---|
| Age (years) | |
| 20–29 | 44% (7) |
| 30–39 | 56% (9) |
| Level of education | |
| Diploma or lower | 31% (5) |
| University student | 19% (3) |
| University degree | 50% (8) |
| Career | |
| No formal occupation | 31% (5) |
| Formal occupation | 69% (11) |
| Ethnicity | |
| Caucasian | 25% (4) |
| African or Middle Eastern | 44% (7) |
| Asian | 31% (5) |
| Overarching theme | Categories | Main themes | Sub-themes |
|---|---|---|---|
| Confidence | Positive experiences | Effective interpersonal relationships |
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| Knowledge promotion |
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| Positive self-concept |
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| Negative experiences | Lack of control |
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| Feeling unprepared |
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Positive experiences
Positive experiences raised in the interviews related to themes of effective interpersonal relationships, knowledge promotion and positive self-concept, and made the women feel more confident.
Effective interpersonal relationships
We identified three subthemes of effective interpersonal relationships: practical support, shared decision-making and reassurance. First-time mothers said that the support and care provided by their partners, family members (their mother, cousin, sister-in-law and mother-in-law were mentioned), employers and healthcare providers throughout their pregnancy, labour and birth contributed strongly to their feeling reassured and confident. The nominated support provided by their partners included emotional support, helping with chores and food preparation during pregnancy, holding their hands and massaging them during labour, and helping care for the baby after birth. For example, one woman said:
‘If I had concerns about whatever it is, we could just talk through it. It kind of made it [our relationship] stronger, just because he was more aware and there for me that way.’
Another woman said:
‘…he really does everything for me, like every morning he prepares different fruits for me, and he learns to cook Chinese dishes to make me happy. He also takes on the majority of our housework, from laundry to cleaning, everything…’
The family members also supported the women through sharing their own experiences and helping with the baby care. One woman mentioned that her employer was understanding and her colleagues provided flexible working arrangements, and she could work from home during her pregnancy when travelling to work was an issue:
‘My company, because the bosses are all women, are also supportive. And I can work from home—that's also a benefit.’
The support from healthcare providers occurred through communication and reassurance. Healthcare providers incorporated shared decision-making into their model of care and allowed women to be more involved in their care. Women were provided with options so they were not restricted to following the instructions from the clinicians. One woman said:
‘I did have the option to go home [in early labour] but also I didn't really want to … [so they] gave me options and let me decide.’
Another woman mentioned:
‘…postpartumly, the midwives here really helped me with breastfeeding and understanding baby's behaviours on different days after birth…’
Also, one woman stated:
‘I felt included in the handover process … they would come and introduce me to who was coming on next and would ask questions…’
Knowledge promotion
We identified three subthemes, including hospital educational classes, online materials and advice from family and friends. Women revealed that they obtained knowledge about changes during pregnancy, the labour and birth process, and caring for their baby through a variety of sources. They attended antenatal and/or postpartum education classes provided by the hospital, which helped improve their confidence in caring for the baby and understand the baby's behaviour in the early days after birth. For example, one woman said:
‘It improved my understanding of the whole labour process, and how to take care of the baby after that.’
Another woman commented:
‘If I hadn't done the pregnancy classes, I don't think I would've been as informed of … where to come, what to do. Without those classes, I don't think I would've felt as comfortable.’
Apart from hospital education, women also reported that online materials and YouTube videos helped them learn about their body, the labour process and how to act during labour to have a smooth birth. For some other women, however, these were in contradiction with what their midwives had told them and caused confusion. For example, one woman stated:
‘… the midwife would say to me … “push”, and then she'd say, “don't breathe while you're pushing”, like “push, and then take a breath”. But when I was reading and watching videos online, it actually said the opposite—don't just strain and push like that, you should actually breathe the baby out. So, I was conflicted with trying to do that, and then trying to listen to the midwife…’
Family and friends were useful sources of knowledge, and their advice was useful, as they helped the women draw on the advice to boost their confidence.
Positive self-concept
Positive self-concept was shown to have two subthemes, including the empowering effect of pregnancy and birth, and application of life skills. We identified positive self-concept as a theme that enabled women to feel empowered during pregnancy, labour and after the birth. For some women, this was achieved through maintaining good health, and for others, skills that they acquired through prior life experiences were helpful. One woman said:
‘Even though it [pregnancy] was hard, I could handle it because I already had tried [to build up life skills] in the past.”
Another woman said:
‘I've got a lot of young nephews and nieces, so I wasn't scared about having a baby … it helps because you become familiar with certain things.’
Almost half of the women reported feeling empowered by becoming pregnant after a time in which they had dealt with infertility, a miscarriage, or by becoming pregnant in a timely manner. One woman said:
‘It [pregnancy] was something that I'd been trying for a long time, about three to four years … I couldn't believe it that I was pregnant for a few days … because it's something I really wanted. I was extremely happy to find out I was pregnant.’
Another woman who previously had a miscarriage reported the following:
‘Four months after [my] miscarriage, I got pregnant again, so my confidence level went up … my confidence level is top of the world now.’
Negative experiences
Themes of negative experiences included lack of control and feeling unprepared, and made the women feel less confident in their mothering capabilities.
Lack of control
Four subthemes of lack of control (including maternal medical conditions, fetal medical conditions, length of postpartum hospital stay, conflicting advice and stressful life events) were reported as negatively affecting the women's level of confidence, especially first-time mothers. Some women mentioned that a pre-existing condition during pregnancy (eg diabetes or asthma) made them worried about the wellbeing of the fetus. Others reported that fetal conditions or complications that arose during pregnancy (eg fetus' enlarged kidneys diagnosed during an antenatal scan), during labour (eg fetal heart rate complications), or after the birth (low blood sugar in the baby) made them feel uncertain and stressed about the outcome. For example, one woman said:
‘When I first found out I was pregnant, my first worry was how am I going to go with pregnancy and also birth with my asthma, because it can be really severe … so I thought that with the extra stress of pregnancy, and everything else, and the body … that it [the asthma] might flare up quite badly towards the end, and then I would struggle to push, and it would just be a disaster…’
Another woman said:
‘Every time there was a major check for the baby, I would feel nervous when waiting for the results.’
Although a few women had to stay longer in the hospital after birth due to either their own recovery issues (eg high blood pressure or slow recovery after c-section) or the baby's condition (eg feeding problems, meconium aspiration, blood tests or ultrasound), many reported that they preferred to stay for less time at the hospital; for one or a maximum of two days after birth. The reasons were that they felt more comfortable at home, could get into routines, wanted to be in their own environment and could have their partners by their side.
Several women pointed out the difficulty of looking after their newborn alone in hospital overnight, exacerbated by the unfamiliar environment of the hospital. As the baby's behaviour would vary greatly from night to night, they preferred having their partner or family member stay to provide initial support and were dissatisfied by the lack of understanding from clinicians. One woman commented:
‘I just had a really tough night last night, I think because I wasn't in my own environment, in my own house. And they don't let your partner stay, so I was by myself.’
Some women reported instances where conflicting advice was given by clinicians. These issues primarily stemmed from miscommunication, causing confusion while the women were adjusting to new routines with the arrival of baby. For instance, one woman expressed dissatisfaction due to conflicting advice she received:
‘One [midwife] told me to do it [wrap the baby] that way, and so you do that way. And then the other one comes in, and gets angry at you because “why did you do it that way?”’
For some women, major life events coinciding with their pregnancies exacerbated their stress, such as family matters occurring during the pregnancy, having an unsupportive partner and immigration problems. For example, one woman, who had recently immigrated to Australia, shared that she worried about her family members due to political unrest in her home country:
‘I was not even talking to them [family members], it was so serious … I didn't even know if they were okay, if they were alright, I don't know anything. Then the relationship uncertainty between you and the father, you don't even know how to go along with the father…’
Feeling unprepared
Women who felt unprepared attributed it to a lack of knowledge, as well as uncertainty around their pregnancy and, in particular, the labour process. This resulted in feeling unconfident in addressing potential issues that might have occurred during pregnancy and labour, as well as when caring for the baby. Clashes with other duties meant that a few women were unable to attend the hospital education classes, as was described by one woman:
‘I was working, and my time and shift timing clashed, so I wouldn't get time to do that.’
Some women declared that there must be more emphasis on the importance of attending the hospital classes and that midwives need to push for it. However, even some women who did attend antenatal education classes felt anxious at times, due to uncertainty about what could happen during pregnancy, labour and birth. One woman reported:
‘I went into labour on Tuesday … they [contractions] were irregular, so we didn't know if we were in labour, and so there was that uncertainty, and not knowing if this was normal, or what was happening…’
Discussion
To the knowledge of the authors, this is the first qualitative study in this tertiary hospital that investigated women's experiences of pregnancy, labour, birth and the immediate days after birth. We discovered the overarching theme of confidence and five main themes, including effective interpersonal relationships, knowledge promotion and positive self-concept (the three positive themes), a lack of control, and feeling unprepared (the two negative themes).
Our study showed that confidence is the fundamental basis of motherhood. The challenges of pregnancy, labour and birth helped some of the women gain a new perspective of themselves and feel more confident. On the other hand, negative experiences of the perinatal period made some others feel less confident in their mothering capabilities. According to our findings, one essential feature of the women's confidence during the perinatal period that emerged was knowledge. Women who did not attend hospital educational classes or felt unprepared due to a lack of knowledge expressed low confidence in their capabilities in caring for the baby.
In contrast, women who attended hospital education classes, read online materials, received advice from family and friends or had some relevant life skills reported that they felt knowledgeable and were prepared for the changes. These findings are in accordance with previous reports in the literature. For example, a qualitative study (Luyben and Fleming, 2005) conducted in three European countries assessed the antenatal care needs of pregnant women and showed that providing new information to pregnant women can help increase their confidence and gain understanding about their pregnancy and birth. This study also found that women need clear, detailed information that can be integrated into their prior knowledge.
Another study by Larsson (2009) showed that although pregnant women frequently used the internet to find information on matters related to pregnancy, the wellbeing of the fetus, labour, birth and postpartum care, they rarely discuss it with their midwives. It has been suggested that midwives and other healthcare providers, who look after pregnant women, need to guide the pregnant women to high-quality, reliable resources and take the opportunity to discuss this information with them during antenatal and postpartum visits (Larsson, 2009).
According to the interviews with our participants, it appears that we have achieved this aim in our practice through providing reassurance and practical support during the perinatal period. Women in our study reported that attending educational classes on labour, birth and baby care during pregnancy helped them gain new knowledge and fulfill their need for a refresher class after birth.
Individualised advice and support, along with shared decision-making, can empower women, enhance their strengths and increase the chance of positive pregnancy and birth experiences (Nilsson et al, 2013). In our study, women reported that shared decision-making about their care and outcomes allowed them to gain a sense of reassurance and increased their confidence. Our findings support the reports of a Cochrane review of shared decision-making tools that showed involving patients in the decision-making process has several advantages, such as more informed value-based choices, improved communication between patient and clinicians, improved patient knowledge, more realistic expectations of outcomes, and increased patient satisfaction (Stacey et al, 2017).
Another systematic review showed that shared decision-making in maternity care can improve women's knowledge, decrease conflict between the woman and clinicians, reduce anxiety, enhance the perception of making an informed choice, and promote women's satisfaction (Say et al, 2011). Contemporary maternity care providers attempt to improve women's experiences by delivering positive, satisfying perinatal care that is safe for the mother and the baby (Ménage et al, 2017). These reports indicate that improving the decision-making process for women in the perinatal period can help increase equity in maternity care and enhance outcomes (Attanasio et al, 2018).
Another interesting finding of our study was that many women reported that they preferred to spend less time at the hospital and be discharged home after one or two days (maximum) after birth. Those who had to stay longer due to maternal or neonatal medical conditions felt they had no control over their postpartum care and it negatively affected their confidence. There are considerable variations in usual lengths of postpartum hospital stays between western countries, but a common feature among them is a shortened length of hospital stay after childbirth.
According to the literature, there has been an increase in the proportion of women and newborns who are discharged on the day of childbirth from 2005–2014 (Benahmed et al, 2017). A British report has shown that in 2005–2006, 16.5% of women were discharged on the same day that they gave birth, compared to 20.3% of women in 2013–2014 (Health and Social Care Information Centre, 2015). International studies suggest that the mean length of stay has decreased for both caesarean and vaginal deliveries, although such studies investigated overall lengths of stay rather than postpartum lengths of stay (Wen et al, 1998).
The average postpartum length of stay in Australian public hospitals is 2–3 days following a normal vaginal birth, and 3–4 days after a c-section, and women stay 4–5 days for vaginal birth and c-section, respectively, in private hospitals (Riley et al, 2005).
The shortened length of hospital stay after childbirth was introduced due to the associated costs, availability of hospital beds and an effort to de-medicalise childbirth (Forster et al, 2008). In addition to these reasons, the earlier postpartum discharge was suggested to: support a more family-centred approach to childbirth that allows earlier involvement of fathers and siblings in the care of the newborn; promote rest and sleep for the mother; enhance maternal confidence in raising the child; decrease mother and newborn exposure to nosocomial infections; decrease conflicting advice on breastfeeding (Brown et al, 2009); and provide postpartum care in a safe, cost-effective way (Madden et al, 2002).
To date, there is no standard definition of early postpartum discharge due to large variations in the usual length of stay for vaginal births between countries: in 2011, the mean length of stay for single spontaneous vaginal births was 5.2 days in Hungary, 4.2 days in France, 4 days in Belgium, 2.8 days in Australia, 1.7 days in Canada and 1.5 days in the UK (Organisation for Economic Cooperation and Development, 2014). There is no agreement on how many days is defined as ‘short’ and when the most desirable time is for women to be discharged. In our research, we found support for early discharge after labour, but further research is required to devise a universal definition of early postpartum discharge and how it affects the wellbeing and recovery of women and babies after birth.
Limitations
Our study had some limitations that should be addressed. First, we interviewed only women who could speak English, due to the unavailability of interpreters for this research. This resulted in us missing information on the perinatal experiences of women from culturally and linguistically different backgrounds, who may be more vulnerable to negative perinatal experiences than English-speaking women. Further research should address this issue and study the experiences of non-English speaking pregnant women.
Second, we conducted face-to-face interviews that could have resulted in report bias by the participants. However, because our study was anonymous, with no identifying information disclosed to the healthcare providers caring for the participants in the postpartum ward, we trusted that the participants gave honest responses during their interviews. Further, because participants were not selected randomly, women with positive experiences might have been over-represented.
Also, Westmead Hospital is a public hospital in Western Sydney and the majority of our participants (12/16) were from culturally and linguistically different backgrounds, which might have affected their level of confidence. Since the length of postnatal hospital stay is generally shorter in public hospitals compared to private hospitals and the model of perinatal care can be different between the two settings, if this study had been done in a private hospital women might have reported different experiences. As a result, our findings cannot be generalised to the entire population of postpartum women in Australia, but can operate as an informative aspect within the greater body of knowledge.
Despite these shortcomings, we find it fair to conclude that our study offers important contributions to the literature and supports the case for future studies in this context. Future in-depth interviews are required to refine the nature of questions asked in this study and shape a comprehensive discourse, in order to investigate how pregnancy and postpartum experiences during their hospital stay affect women's confidence.
Implications for practice
The evidence acquired from our research provides important guidance for perinatal education and clinical practice. Although it may not be possible to modify all factors contributing to the perinatal experience of primiparous women, many of them can be altered, which may either prevent a negative experience or help alter their perception of the experience afterwards.
First-time mothers and their partners should be informed about the importance of attending antenatal education classes that can help them prepare for their new roles and responsibilities. Obtaining appropriate knowledge can also help them feel positive about their perinatal experiences and enhance their confidence.
Because it is important for women to feel they have control over their care, it is essential that they take part in any decision-making activity related to their health and outcomes. During perinatal visits, midwives and other healthcare providers who are in close contact with the women should effectively attend to their needs by providing timely support, guidance, education, counselling and reassurance, and should individualise their care to enhance positive experiences and minimise negative ones.
Conclusion
Confidence was the overarching theme in our study, and knowledge was shown to be the fundamental feature of confidence. Five main themes emerged, including the positive themes of effective interpersonal relationships, knowledge promotion and positive self-concept, and the negative themes of lack of control and feeling unprepared.
Some women gained a new perspective of themselves and felt more confident after facing the challenges of pregnancy, labour and birth, while others felt less confident about their mothering capabilities due to their negative experiences of the perinatal period.