Midwifery Matters - Childbirth: Issues, contexts, outcomes

Enhancing women’s childbirth experiences requires the consideration of the multidimensional characteristics of childbirth

Childbirth is usually evaluated by using statistical measures that focus on physical morbidity and mortality, often overlooking other dimensions such as emotional and psychological wellbeing. Although physical consequences are important, they provide little information about the impact or the significance of childbirth.

The Nursing and Midwifery Board advocates the provision of holistic midwifery care including emotional, psychological and spiritual wellbeing.1 Evidence-based midwifery care should therefore encompass an awareness of the psychological and emotional responses to childbirth experiences in addition to physical ones.

Significance of experiences
Positive birth experiences are associated with long-lasting benefits such as a close relationship with the baby and an optimistic attitude towards motherhood that contributes to women’s self-esteem and feelings of achievement.2 Negative birth experiences may significantly impact on women’s physical and emotional wellbeing, including problems with infant attachment3 and life-long psychological effects for both her and the family.4

Psychological morbidity includes anxiety, postnatal depression, and posttraumatic stress disorder (PTSD).5 Women can experience transient feelings of panic,2 however, sustained traumatic distress produces recurrent feelings of helplessness, intense terror, and horror, because women feared serious injury during childbirth.6

Reactions to a traumatic birth can cause a woman to avoid future pregnancies2 or opt for an elective caesarean for subsequent births.7 Commonalities between depression and PTSD exist, but whatever diagnostic criteria are applied, there are important psychological and emotional dimensions to childbirth experiences.

Researching experiences
Methodological difficulties in identifying women distressed by childbirth experiences abound. What appears to be ‘routine’ births to professionals may be experienced as traumatic by women.5 The traditional means of asking women about childbirth using satisfaction measures before they leave hospital has many limitations. Satisfaction is a complex multidimensional concept difficult to define8 and is often indiscriminate in identifying aspects of experiences that are positive and those that are not.

Women are discharged so soon after childbirth it is difficult to ascertain the extent that women have been distressed by childbirth. Women may feel physically and emotionally vulnerable soon after the birth. The ‘halo effect,’ where women experience euphoria and relief after having a live, healthy baby, means that women are less likely to be negative about their childbirth experiences9 or criticise their care.

In Ireland, due to the limited provision of postnatal care services, there is little evidence about women’s postnatal psychological wellbeing. A recent survey by the Association for Improvement of Maternity Services (AIMSI) found that 37% of respondents said that they were not asked about their psychological wellbeing at their six-week postnatal appointment.10 In the context of 74,650 annual births in Ireland,11 many women may be suffering in silence.

Important elements
Childbirth experiences are difficult to disassemble, but there are common elements that are important to many women – the transformational potential of childbirth as a ‘life event’ and potential stressor is a recurring theme.11 A feeling of support, being in control and having choices during childbirth are interrelated and constitute important components of childbirth.11

Women’s expectations, pain management and relationship with caregivers can influence childbirth experiences.11 Supportive midwifery care can protect women from negative childbirth experiences.12

Quality of healthcare
Childbirth experiences are an indicator of the quality of maternity care.14 Women’s assessment of their experience is intertwined with the quality of support and services available to them.2 HIQA advocates a healthcare system that puts the consumer at the centre of the services, is responsive to individual needs, and actively involves them in the provision of care.14 These goals align with the midwife’s role in providing evidence-based, womencentred, holistic care.1

Improving experiences
Midwifery-led care aspires to provide a more social, less medicalised model, that is conducive to enhancing childbirth and recognising it as a life event.15 Although present maternity policies advocate expanding community and midwifery-led services,16,17 changes in maternity services are slow. A recently developed midwiferyled unit has been threatened with closure unit on the pretext of saving resources,18 despite evidence demonstrating that it was as cost effective and safe as consultant- led care.15

Enhancing women’s childbirth experiences requires researchers and practitioners to consider the multidimensional characteristics of childbirth. Congruent with current health quality and policy recommendations, further development of models of care that recognise the importance of childbirth experiences need to be sustained and developed. All practitioners, managers and policy makers can help to enhance childbirth experiences by raising their awareness of the powerful potential it has for women their babies, families, and communities.

Patricia Larkin is a midwifery lecturer at Dundalk Institute of Technology

References on request from nursing@medmedia.ie (Quote: Midwifery Matters. WIN 2013; 21(1): 50)

Midwifery Matters - Childbirth: Issues, contexts, outcomes

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