Developing a woman-centered, inclusive definition of positive childbirth experiences: A discussion paper.

INTRODUCTION: A positive childbirth experience promotes women's health, both during and beyond the perinatal period. Understanding what constitutes a positive childbirth experience is thus critical to providing high-quality maternity care. Currently, there is no clear, inclusive, woman-centered definition of a positive childbirth experience to guide practice, education, and research. AIM: To formulate an inclusive woman-centered definition of a positive childbirth experience. METHODS: A six-step process was undertaken: (a) Key concepts associated with a positive childbirth were derived from a rapid literature review; (b) The key concepts were used by interdisciplinary experts in the author group to create a draft definition; (c) The draft definition was presented to clinicians and researchers during a European research meeting on perinatal mental health; (d) The authors integrated the expert feedback to refine the working definition; (e) A revised definition was shared with women from consumer groups in six countries to confirm its face validity; and (f) A final definition was formulated based on the women's feedback (n = 42). RESULTS: The following definition was formulated: "A positive childbirth experience refers to a woman's experience of interactions and events directly related to childbirth that made her feel supported, in control, safe, and respected; a positive childbirth can make women feel joy, confident, and/or accomplished and may have short and/or long-term positive impacts on a woman's psychosocial well-being." CONCLUSIONS: This inclusive, woman-centered definition highlights the importance of provider interactions for facilitating a positive childbirth experience. Feeling supported and having a sense of control, safety, and respect are central tenets. This definition could help to identify and validate positive childbirth experience(s), and to inform practice, education, research, advocacy, and policy-making.

Developing a woman-centered, inclusive definition of traumatic childbirth experiences: A discussion paper.

INTRODUCTION: Many women experience giving birth as traumatic. Although women's subjective experiences of trauma are considered the most important, currently there is no clear inclusive definition of a traumatic birth to help guide practice, education, and research. AIM: To formulate a woman-centered, inclusive definition of a traumatic childbirth experience. METHODS: After a rapid literature review, a five-step process was undertaken. First, a draft definition was created based on interdisciplinary experts' views. The definition was then discussed and reformulated with input from over 60 multidisciplinary clinicians and researchers during a perinatal mental health and birth trauma research meeting in Europe. A revised definition was then shared with consumer groups in eight countries to confirm its face validity and adjusted based on their feedback. RESULTS: The stepwise process confirmed that a woman-centered and inclusive definition was important. The final definition was: "A traumatic childbirth experience refers to a woman's experience of interactions and/or events directly related to childbirth that caused overwhelming distressing emotions and reactions; leading to short and/ or long-term negative impacts on a woman's health and wellbeing." CONCLUSIONS: This definition of a traumatic childbirth experience was developed through consultations with experts and consumer groups. The definition acknowledges that low-quality provider interactions and obstetric violence can traumatize individuals during childbirth. The women-centered and inclusive focus could help women to identify and validate their experiences of traumatic birth, offering benefits for practice, education, and research, as well as for policymaking and activism in the fields of perinatal mental health and respectful maternity care.

The third paradigm in labour pain preparation and management: the childbearing woman's paradigm.

THE STUDY'S RATIONALE: Women's experiences regarding labour pain preparation and management have been largely neglected. AIMS AND OBJECTIVES: Explore women's experiences regarding labour pain preparation and management in normal childbirth. METHODOLOGICAL DESIGN AND JUSTIFICATION: The Vancouver School of doing phenomenology was the methodological approach of the study since it provides inside information about the lived experience. RESEARCH METHODS: Data were collected through in-depth interviews with 14 participants; seven primiparous and seven multiparous women. RESULTS: The women described a challenging journey of no return through labour pain, with different landmarks on the journey. They described how they prepared for the pain; the context of the pain experience; how they experienced and managed the pain with different strategies and how they saw the pain at the journey's end. The quality of the midwife's presence and professionalism was of great importance to them. The 'good midwives' they described created a special atmosphere which was warm and secure and was conducive to their managing the pain. The women also described how important it was for them to have a supportive partner, with whom they had a mutual understanding, in order to manage the pain. CONCLUSIONS: In this paper, we are presenting a study within the third paradigm in labour pain preparation and management: the childbearing woman's paradigm - the first and second being the midwifery and the medical paradigm, respectively. Midwives can play a major role in working with women in their preparation and management of labour pain. In the future, more research has to be done to illuminate this essential part of the childbearing woman's paradigm.

Traumatic birth and childbirth-related post-traumatic stress disorder: International expert consensus recommendations for practice, policy, and research.

BACKGROUND: Research suggests 1 in 3 births are experienced as psychologically traumatic and about 4% of women and 1% of their partners develop post-traumatic stress disorder (PTSD) as a result. AIM: To provide expert consensus recommendations for practice, policy, and research and theory. METHOD: Two consultations (n = 65 and n = 43) with an international group of expert researchers and clinicians from 33 countries involved in COST Action CA18211; three meetings with CA18211 group leaders and stakeholders; followed by review and feedback from people with lived experience and CA18211 members (n = 238). FINDINGS: Recommendations for practice include that care for women and birth partners must be given in ways that minimise negative birth experiences. This includes respecting women's rights before, during, and after childbirth; and preventing maltreatment and obstetric violence. Principles of trauma-informed care need to be integrated across maternity settings. Recommendations for policy include that national and international guidelines are needed to increase awareness of perinatal mental health problems, including traumatic birth and childbirth-related PTSD, and outline evidence-based, practical strategies for detection, prevention, and treatment. Recommendations for research and theory include that birth needs to be understood through a neuro-biopsychosocial framework. Longitudinal studies with representative and global samples are warranted; and research on prevention, intervention and cost to society is essential. CONCLUSION: Implementation of these recommendations could potentially reduce traumatic births and childbirth-related PTSD worldwide and improve outcomes for women and families. Recommendations should ideally be incorporated into a comprehensive, holistic approach to mental health support for all involved in the childbirth process.

Key dimensions of women's and their partners' experiences of childbirth: A systematic review of reviews of qualitative studies.

BACKGROUND: The World Health Organization 2018 intrapartum guideline for a positive birth experience emphasized the importance of maternal emotional and psychological well-being during pregnancy and the need for safe childbirth. Today, in many countries birth is safe, yet many women report negative and traumatic birth experiences, with adverse effects on their and their families' well-being. Many reviews have attempted to understand the complexity of women's and their partners' birth experience; however, it remains unclear what the key dimensions of the birth experience are. OBJECTIVE: To synthesize the information from reviews of qualitative studies on the experience of childbirth in order to identify key dimensions of women's and their partners' childbirth experience. METHODS: Systematic database searches yielded 40 reviews, focusing either on general samples or on specific modes of birth or populations, altogether covering primary studies from over 35,000 women (and >1000 partners) in 81 countries. We appraised the reviews' quality, extracted data and analysed it using thematic analysis. FINDINGS: Four key dimensions of women's and partners' birth experience (covering ten subthemes), were identified: 1) Perceptions, including attitudes and beliefs; 2) Physical aspects, including birth environment and pain; 3) Emotional challenges; and 4) Relationships, with birth companions and interactions with healthcare professionals. In contrast with the comprehensive picture that arises from our synthesis, most reviews attended to only one or two of these dimensions. CONCLUSIONS: The identified key dimensions bring to light the complexity and multidimensionality of the birth experience. Within each dimension, pathways leading towards negative and traumatic birth experiences as well as pathways leading to positive experiences become tangible. Identifying key dimensions of the birth experience may help inform education and research in the field of birth experiences and gives guidance to practitioners and policy makers on how to promote positive birth experiences for women and their partners.

The primacy of the good midwife in midwifery services: an evolving theory of professionalism in midwifery.

Theory is the acknowledged foundation to practise methodology, professional identity and growth of formalized knowledge. It has been noted that practice must not only be evidence-based but also theory-based. Hence, midwifery must be theory based because theories serve as a broad framework for practice and may also articulate the goals of a profession and core values. In this paper, an evolving theory on the empowerment of childbearing women is introduced, where the midwife's professionalism is central. The theory is synthesized from nine datasets and scholarly work, and then more than three hundred studies were reviewed for clarification and confirmation. According to the theory, the midwife's professionalism is constructed from five main aspects: The professional midwife cares for the childbearing woman and her family. This caring within the professional domain is seen as the core of midwifery. The professional midwife is professionally competent. This professional competence must always have primacy for the sake of safety of woman and child. The professional midwife has professional wisdom and knows how to apply it. Professional wisdom is a new concept used to denote the interplay of knowledge and experience. The professional midwife has interpersonal competence, is capable of empowering communication and positive partnership with the woman and her family. The professional midwife develops herself both personally and professionally, which is the prerequisite for true professionalism. This evolving theory must be regularly reconstructed in the light of current knowledge within midwifery. It is an attempt to identify and articulate the processes and components of the art and science of midwifery practice in an endeavour of continuing the discipline's development by assisting in the understanding and practice of creating further theoretical discourse, processes and products for midwifery practice. The theory has implications for midwifery education and practice.

Birth as a neuro-psycho-social event: An integrative model of maternal experiences and their relation to neurohormonal events during childbirth.

BACKGROUND: Psychological aspects of labor and birth have received little attention within maternity care service planning or clinical practice. The aim of this paper is to propose a model demonstrating how neurohormonal processes, in particular oxytocinergic mechanisms, not only control the physiological aspects of labor and birth, but also contribute to the subjective psychological experiences of birth. In addition, sensory information from the uterus as well as the external environment might influence these neurohormonal processes thereby influencing the progress of labor and the experience of birth. METHODOLOGY: In this new model of childbirth, we integrated the findings from two previous systematic reviews, one on maternal plasma levels of oxytocin during physiological childbirth and one meta-synthesis of women´s subjective experiences of physiological childbirth. FINDINGS: The neurobiological processes induced by the release of endogenous oxytocin during birth influence maternal behaviour and feelings in connection with birth in order to facilitate birth. The psychological experiences during birth may promote an optimal transition to motherhood. The spontaneous altered state of consciousness, that some women experience, may well be a hallmark of physiological childbirth in humans. The data also highlights the crucial role of one-to-one support during labor and birth. The physiological importance of social support to reduce labor stress and pain necessitates a reconsideration of many aspects of modern maternity care. CONCLUSION: By listening to women's experiences and by observing women during childbirth, factors that contribute to an optimized process of labor, such as the mothers' wellbeing and feelings of safety, may be identified. These observations support the integrative role of endogenous oxytocin in coordinating the neuroendocrine, psychological and physiological aspects of labor and birth, including oxytocin mediated. decrease of pain, fear and stress, support the need for midwifery one-to-one support in labour as well as the need for maternity care that optimizes the function of these neuroendocrine processes even when birth interventions are used. Women and their partners would benefit from understanding the crucial role that endogenous oxytocin plays in the psychological and neuroendocrinological process of labor.

[The effects of induced labor at 41 week of pregnancy on mode of delivery and outcome].

INTRODUCTION: Rates of induction of labor (IOL) in Iceland and most neighboring countries have increased. Recent literature on IOL provided contradicting effects on mode of delivery, maternal and neonatal outcome. MATERIAL AND METHODS: The aim of this study was to evaluate the impact of IOL in late term pregnancies (≥41 weeks) on mode of delivery, maternal and neonatal outcome. A retrospective cohort study of deliveries after 41 weeks of pregnancy was conducted for all deliveries in Landspitali in the period 2013-2016, comparing outcomes of IOL deliveries to spontaneous labor deliveries. Logistic regression analysis was performed to determine the impact of the independent variables on the outcome. RESULTS: Of the 2419 women cohort, 61.8% had a spontaneous onset of labor and 38.2% had IOL. The results show that IOL increases probability of caesarean section in primiparas women (p<0.01). IOL increases the use of epidural anesthesia in labor, both for primiparas (p<0.001) and multiparas (p<0.05). Similar results where observed in the neonatal outcome in both groups. Gestational age increases the probability of instrumental delivery (p<0.05), caesarean section (p<0.01), use of epidural anesthe-sia (p<0.01), Apgar <7 at 5 minutes (p<0.01) and fetal distress (p<0.01). CONCLUSION: Induction of labor has some negative impact on maternal outcome but leads at the same time to a shorter preg-nancy, which again decreases negative impact of prolonged pregnancy. It is important to evaluate the advantages and disadvantages of induction of labor before making a decision when to induce labor.

Predictors of women's positive childbirth pain experience: Findings from an Icelandic national study.

BACKGROUND: Pain in childbirth has been identified as one of the major components in the childbirth experience and an important topic that needs to be addressed during pregnancy, birth and the after-birth period. AIM: The aim of the study was to describe women's childbirth pain experience and to identify predictors of women's positive childbirth pain experience. METHOD: A population-based cross-sectional cohort study design was implemented, with convenient consecutive sampling, stratified according to residency. Pregnant women were recruited through 26 health care centers. Participants were sent a questionnaire by mail during early pregnancy and another one five to six months after childbirth. A multiple regression analysis was done, with women's childbirth pain experiences as the dependent variable. FINDINGS: Altogether 726 women participated in the study, with a response rate of 68%. The strongest predictors for women's positive childbirth pain experience were positive attitude to childbirth during pregnancy; support from midwife during childbirth; use of epidural analgesia and low intensity of pain in childbirth. DISCUSSION: The majority of the women in the study experienced childbirth pain as a positive experience, which is in line with studies that have demonstrated that pain in childbirth is different from other kinds of pain. In addition to epidural use as a predictor for positive childbirth pain experience, many other strong predictors exist and must be acknowledged. CONCLUSION: When planning pregnancy and childbirth services, predictors of positive experience of childbirth pain should be considered and investigated further.

Women's psychological experiences of physiological childbirth: a meta-synthesis.

OBJECTIVE: To synthesise qualitative studies on women's psychological experiences of physiological childbirth. DESIGN: Meta-synthesis. METHODS: Studies exploring women's psychological experiences of physiological birth using qualitative methods were eligible. The research group searched the following databases: MEDLINE, CINAHL, PsycINFO, PsycARTICLES, SocINDEX and Psychology and Behavioural Sciences Collection. We contacted the key authors searched reference lists of the collected articles. Quality assessment was done independently using the Critical Appraisal Skills Programme (CASP) checklist. Studies were synthesised using techniques of meta-ethnography. RESULTS: Eight studies involving 94 women were included. Three third order interpretations were identified: 'maintaining self-confidence in early labour', 'withdrawing within as labour intensifies' and 'the uniqueness of the birth experience'. Using the first, second and third order interpretations, a line of argument developed that demonstrated 'the empowering journey of giving birth' encompassing the various emotions, thoughts and behaviours that women experience during birth. CONCLUSION: Giving birth physiologically is an intense and transformative psychological experience that generates a sense of empowerment. The benefits of this process can be maximised through physical, emotional and social support for women, enhancing their belief in their ability to birth and not disturbing physiology unless it is necessary. Healthcare professionals need to take cognisance of the empowering effects of the psychological experience of physiological childbirth. Further research to validate the results from this study is necessary. PROSPERO REGISTRATION NUMBER: CRD42016037072.

Pregnant women's expectations about pain intensity during childbirth and their attitudes towards pain management: Findings from an Icelandic national study.

BACKGROUND: Pregnant women expect childbirth to be painful. However, little is known about their expectations of the intensity of pain in childbirth (EIPC) and their attitudes to pain management. METHOD: The design was a cross-sectional survey, with self-reported questionnaires used to collect data from low-risk pregnant women (N = 1111) early in pregnancy at 26 of the largest primary health care centres in Iceland. This consecutive national sample was stratified by residency. RESULTS: The mean score for the EIPC was 5.58 (SD = 1.38) measured on a 7 point scale. The strongest predictors of a high EIPC score were: negative attitude to the impending childbirth (OR = 2.39), low manifestation of a sense of security (OR = 1.80), and a positive attitude to pain management with medication (OR = 1.63). Women living outside the capital area were less likely to have a high EIPC (OR = 0.68). Most women (77%) had a positive attitude towards pain management without medication and 35% had a positive attitude to pain management with medication. CONCLUSIONS: The study detected multiple predictors of women's EIPC and attitude to pain management. Early and throughout pregnancy, midwives and health care professionals need to address these predictors in order to assist women to prepare themselves for the pain of labour.