Implementing safe maternal care is a worldwide concern. Optimal care should be provided during the antenatal, intrapartum and postpartum periods, and should include both the mother and infant (World Health Organization (WHO), 1994; 1996; 2014). In Western countries, births usually take place in hospitals with equipment and personnel to deal with unexpected situations relating to health concerns (Kunnskapssenteret, 2006). The Norwegian Directory of Health emphasises continuity of care. Beyond evidence-based practice in midwifery, there is also a need to address underpinning theory (Halldorsdottir and Karlsdottir, 2011). Holistic care involves considering and supporting the interaction between the patient's physical, mental and social health, and state of mind (Haugan and Rannestad, 2014).
An alternative birth clinic (ABC) features strong elements of supporting the empowerment of women, alongside the professional integrity of midwives. ABCs seek to present a less routine-based, more homely atmosphere compared to hospital units, with an environment featuring specially chosen colours, furniture and plants (Homer, 2013). ABCs support normal birth as the gold standard for giving birth. WHO (1996: 4) defines normal birth as
‘spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery… After birth mother and infant are in good condition.’
Important elements of ABCs include the philosophy of the woman and midwife making decisions together, a holistic environment to engender the feeling of a safe haven, as few interventions in the birth process as possible, and the women having optimal control (Cook and Loomis, 2012). Not all women can be admitted to an ABC; women with a former history of birth complications, who want pharmacological pain relief or are expecting more than one baby are excluded from ABCs in Norway (Holan, 2000).
Empowerment is defined as helping people to assert control of factors affecting their lives (Gibson, 1991). Several studies have pointed to important principles underpinning midwifery (Bergsjø et al, 2006; Pewitt, 2008; Lindgren and Erlandsson, 2010):
The pregnancy and birth processes are extremely important, influencing each individual woman's state of mind and social interactions and requiring a holistic approach to care (Hermansson and Mårtensson, 2011). Hewitt and Hangsleben (1981) pointed to the woman's coping abilities in techniques during childbirth and care for the newborn (Waldenstrøm et al, 2004). Negative birth experiences may be associated with post-traumatic stress disorder (Garthus-Niegel et al, 2013) and postnatal depression (Dennis and Chung-Lee, 2006).
Aims
The aim of this study was to explore whether important factors promoting optimal health for woman and child during pregnancy, birth and post-birth are implemented in ABCs. Research questions were:
Methodology
Setting of the study
The ABC was situated in a medium-sized town, and admitted 500 women each year. Pregnant women need to apply for admission to the ABC. The midwives in this study were employed at the ABC and also performed the pregnancy and post-birth examinations of woman and baby. Women admitted to the ABC stay for approximately 48 hours before discharge. The rooms have a homely environment with enough space for the woman's next of kin to sleep or stay.
Design of the study
As no other studies were found to tell whether midwives' practice was in concordance with the philosophy of ABCs and the role of empowerment, the design of this study was exploratory and qualitative, in order to gain insight.
The authors identified important factors in ABCs according to the holistic treatment model in the philosophy of ABCs. In-depth interviews with midwives were conducted. This method provided information on the integration of theory in the clinic and may be described as validation of the clinical work of the midwives because they seek to provide care according to their philosophy. The exploratory part of the study was to identify factors not described in the theoretical framework.
Interviews took place in the ABC. Five midwives were interviewed, with each interview lasting 45–60 minutes.
Sample
The first author requested to undertake a study in the ABC and provided both oral and written information about the study. Permission from leaders of the ABC and the Norwegian Social Science Data Services was sought before the study began. The first author informed midwives in the ABC of the study and those interested in participating were chosen as informants. The leader of the ABC provided a room and found time in the schedules where all midwives could participate within their working hours. The five midwives who participated gave oral and written consent to participate in the study.
Inclusion criteria were previous experience of working in an ordinary birth clinic and now having worked in the ABC for more than 3 years.
The semi-structured in-depth interview guide covered topics such as description of the ideology of ABCs, what comprised a normal day, and the importance of the relationship between midwives and pregnant women. All questions were open-ended to collect an optimal amount of information. The role of the interview guide was to gather sufficient data to answer our research questions.
Data collection
Interviews were conducted on five occasions and audio-taped. The interviews were transcribed by the first author and the analysis identified text to enlighten the categories from the literature as well as create new categories. In the last two interviews, no new information came up, suggesting data saturation. The audio recordings were stored safely behind two locked doors and one locked closet; only the first author had access. The recordings were deleted following transcription. Confidentiality was secured in the transcripts by removing text that could identify the participant.
Data analysis
The aim of the analysis was connecting the empirical statements and results, and accurately interpreting the midwives' statements. The first author completed the analysis. The material was decontextualised—a process of extracting text, signs or meaning from its original context to establish meaningful associations (Malterud, 2003). This yielded factors that enlightened the authors' theoretical understanding. Kvale (2001) and Bengtsson (2006) describe three contexts for interpretation of text: self-understanding, critical understanding and theoretical understanding. The three contexts can be understood separately, but together they help to interpret the interviews in a holistic view of the material to identify unique and common experiences and statements.
Ethics
The study was registered at the Norwegian Social Science Data Services. All the midwives were informed of their right to withdraw from the study. The midwives were given written information of the study and contact information for the first author.
Limitations
One limitation of this study is the small number of participants (n=5). The midwives who participated were supportive of the philosophy of ABCs, which could constitute bias. As only midwives who work in an ABC were interviewed, and not midwives from an ordinary birth clinic, we have no information as to whether both groups share the same philosophy. In addition, the study did not take into consideration different cultural aspects of giving birth, which may be significant due to migration in Europe. Such cultural factors should be a focus of future studies.
Results
The first research question concerned the implementation of the philosophy of ABCs in the daily work of midwives (Table 1). According to the midwives interviewed, women should feel safe in order to accept and learn from information, practical training, and how to use their own bodies in reducing pain in the birth process. All midwives emphasised the homely atmosphere of the ABC as an important factor in the women's experience of having some sense of equality. The midwives were under the strong impression that the women did not care too much if they were seen by different midwives, as long as the midwives shared the same ideas and philosophy.
| Categories | Important factors for good outcomes |
|---|---|
| Women's ability to cope | Safe environments e.g. trusting midwives |
| Environmental issues | Homely atmosphere for mothers e.g. personalised and with proper hygienic standards |
| Close distance to a hospital | Low-risk pregnancies e.g. no identified risk of complications |
| Avoiding medication where possible | Natural mechanisms in pain coping e.g. physical antenatal activities, finding optimal position for birth, massages, acupuncture etc |
| Relational context* | Shared philosophy, exchanging information and building on maternal preferences |
| Summary | Shared commitment to the philosophy of alternative birth clinics, which lessens the risk of contradictionary information and provides optimal coping |
The second question searched for factors promoting empowerment of the women admitted to the ABC (Table 2). The midwives met each woman with respect and an honest wish to empower her both to endure birth and enable learning practical tasks in taking good care of her baby. The identification of each woman's existing knowledge was reported as fundamental for empowering her to cope. The ability to step back and allow the women to gain confidence in her coping was stated as important.
| Categories | Factors to consider | Actions for good outcome |
|---|---|---|
| The woman's resources | Using resources as foundation for coping | Build on the woman's existing knowledge to ensure the best possible birth experience and also as a foundation for practical coping, both in the birth process but also in order to take care of the newborn |
| The woman's ability to make good decisions | Achieving conducive environment |
Midwives should facilitate communication |
| The woman's practical coping | Teaching and practising necessary tasks in giving birth and taking care of the baby | Midwives should identify each woman's ability to learn, and provide information accordingly |
| The midwife's ability to step back in favour of the woman's own coping and decision-making* | Increasing the level of maternal autonomy, independent actions and decision-making to increase confidence in taking care of the baby | When two coping solutions are close to equal, the woman's choice should be heard, as long as the solution does not present any risk to woman or child |
| The role of the midwife in alternative birth clinic* | Monitoring pregnancy, being a good listener, showing interest | Midwives should be patient and be near to the women by being good listeners and showing interest in matters important to the women |
| Summary | Acknowledging and acting on the basis of combined maternal resources, key information and opportunities to practise tasks |
Allowing women to be heard Enable the woman's choice in coping, as long as her decisions are not considered any risk for herself or the baby |
Discussion
Empirical research provides us with an up-to-date understanding of the important factors in pregnancy, childbirth and the postnatal period (Waldenstrøm et al, 2004; Bergsjø et al, 2006; Pewitt, 2008; Lindgren and Erlandsson, 2010; Hermansson and Mårtensson, 2011; Hewitt and Hangsleben, 2011) and these correspond with the factors the ABCs consider as valuable in daily care.
The midwives in this study agreed that ABCs provide holistic care to women, and that women in birth will be treated as equal to midwives, rather than in a paternal or maternal way (Sørensen and Graff-Iversen, 2001).
Coping
To provide women with the resources to make good decisions, the most important factor seemed to be information, practical learning on how to handle pain during the labour process and how to care for the baby after birth (Waldenstrøm et al, 2004). One respondent commented:
‘I try to use the mother's resources and make her confident that she is capable of giving birth and to raise her baby.’
Knowing what is likely to happen during birth and after the baby is born may provide women with a higher sense of control and ability to make decisions. Another respondent stated:
‘We are conscious of including the mother in matters concerning her. She also takes part in discussions and learns why we suggest the different actions.’
Environmental issues
The homely environment of an ABC (Homer, 2013) contributes to a relaxed atmosphere and communication, which is likely to result in reducing stress levels among the women. One of the midwives stated:
‘Many of the mothers tell us that they feel safe and comfortable here.’
ABCs must be carefully planned to meet the hygienic standards for birth settings. The midwives creatively decorated the ABC in a homely manner without breaking any hygienic principles. This reinforced knowledge around hygiene that the women could apply in their own homes.
Close distance to hospital
ABCs are not equipped to deal with emergency situations which may occur during labour, although women admitted to these facilities are considered as low-risk births. Midwives in ABCs have high standards and a high degree of autonomy, according to the midwives in this study and supported in the literature (Adams, 2006). Midwives are trained to discover symptoms that deviate from the norm. One respondent noted:
‘I must have the professional integrity to dare to make decisions on my own.’
Given that the ABC in this study was situated in the same building as a specialised medical hospital, it is understandable that the distance to the hospital was not a topic raised by the midwives. If the ABC was located further away from the ordinary hospital, the midwives in the ABC might focus more on emergency situations and the significance of distance from an ordinary hospital birth clinic.
Avoiding medication where possible
The midwives in this study reported that ABC midwives are highly skilled in alternative methods to reduce or cope with pain during labour, such as water birth, acupuncture or massages.
A recent study has suggested that complementary medicine (e.g. acupuncture, massages and bathtubs) should be an option in pain reduction during the birth process (Steel et al, 2013). One of the midwives in this study said:
‘It is extremely satisfying working with mothers who are determined to cope with the birth by the use of [their] own body as the sole instrument.’
Relational context
ABC units assign one midwife to be the primary caregiver, guided by the premise that continuity of carer provides safe, sensitive, respectful midwifery care. There is evidence that both women and midwives enjoy this continuity and it works, but few institutions choose to implement continuity of carer schemes (Warren, 2003; Aune et al, 2011).
Owing to factors such as time of birth, midwives' working hours, annual leave and so on, the goal of one midwife following one woman through her entire journey is not always possible. However, sharing the same philosophy and caring practice also provides a sense of security or coherence for women. One of the midwives in this study said:
‘It seems like the mothers don't mind which midwife is present. They say that all of us share the same philosophy and most of the mothers have good relations to all.’
Another important aspect is time for the woman and midwife to interact. This can ease the birth process, which in some cases can be stressful. Stress in the woman could transfer to the infant and result in complications in the birth process (Garthus-Niegel et al, 2013). One of the respondents said of working in the ABC:
‘I have more time and I am more patient…’
‘It seems like the mothers don't mind which midwife is present. They say that all of us share the same philosophy and most of the mothers have good relations to all’
According to the midwives in this study, women seem to value the shared philosophy between the midwives more than the continuity of having one midwife during the process. It seems as if relational context is important but relations are built on the foundation of midwives having the same ideas, respect and sharing of knowledge with the women, rather than the sole presence of one midwife.
Empowerment theory emphasises the process of health professionals making decisions to enable women to gain control and being able to cope in a situation that is somewhat ‘out of control’ (Gibson, 1991).
Women's resources
The midwives in this study reported that the ability of midwives to identify factors that can be controlled or coped with by women during birth is crucial to nurture empowerment. Challenges can arise if complications in the birth process occur. Specialised help may be required, and women who are socialised into handling everything from a normal birth perspective may refuse help. With any complications, the woman in labour is transferred to the regular hospital birth clinic in order to deal with or avoid an emergency situation. Women have no choice in this process and the experience and professional judgement of the midwife is paramount in making such decisions.
Women's ability to make good decisions
Another key element in the philosophy of empowerment is to establish the woman's own responsibility to find the right solutions to challenges (Gibson, 1991). As ABCs often focus on natural birth on the woman's own terms, the approaches are different in the sense of normalising the birth compared to a regular birth unit. The midwives in this study focused on individual information and guidance as the most important factor to empower the woman's coping, such as knowledge about alternative ways of handling pain e.g. acupuncture, massages and different birth positions, and what the midwife can or cannot do in different situations.
The woman's practical coping
Women cannot be expected to make informed decisions on how to cope if they lack knowledge of basic medical issues that may arise during the birth process. In an atmosphere of equality between the midwife and the woman, the professional knowledge of the midwife must be acknowledged as well as the woman's expert views of the perceptions and emotions in the birth process, and this knowledge must be built on to enable coping processes. The professional principle of saving life and promoting health in both woman and child would always supervene if survival is compromised.
The midwife's ability to step back
The midwives in this study emphasised the importance of their stepping back and allowing women to decide how to cope, to empower and enhance maternal confidence.
The midwife's role
The role of the midwife in an ABC is different to that in more traditional, hospital-based birth settings. Midwives in ABCs need to keep up-to-date with the evidence base not only for general midwifery but also that related to specialised birth units such as ABCs.
None of the midwives in this study commented on the need to be close to an ordinary hospital birth unit in case of complications, probably because the ABC in this study was situated in the same building as a medical hospital. Although there is evidence that midwives in an ABC are enthusiastic in the use of complementary and alternative medicine, there is limited research in this field (Hall et al, 2012).
Conclusions
The activities of the midwives in this study reflected the issues described in literature to date, such as high standards and autonomy, relational cooperation, practical and mental coping, and sharing the same philosophy and framework. These issues were reported as being more important than continuity of one-to-one contact with a woman throughout her pregnancy. Guidance to cope both mentally and practically was considered to be the most important thing for empowering women.
ABCs seem to provide a relational service that provides a meaningful bridge between the familiarity of home, midwives' care and the translation of new knowledge about caring for a baby back into the woman's home context. This study could be a reminder to midwives in ABCs to be aware of the importance of the original philosophy, which should be further developed.