research Do women’s ideas of ‘normal’ birth match those held by professionals? Abstract Aim: To explore the definitions of normal birth held by women who have not given birth, what influences that perspective, and compare it with those of health professionals. Background: Available evidence provides conflicting definitions of normal childbirth. The majority of available evidence encapsulates the views of the health professionals themselves or women who have experienced childbirth.
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Little evidence exists that reflects the views of women yet to experience childbirth. Method: Six participants were identified via purposive sampling to undertake a small exploratory qualitative study utilizing semi-structured interviews and thematic analysis. Ethical approval was obtained. Results: The definition of normal birth is individual and complex. The absence of complications and use of interventions influenced this definition, which in part agrees with health professionals’ current definitions.
Birth was perceived as a scary prospect; a view largely constructed from negative stories from friends and family. Conclusions: The findings suggest that working within the confines of a definition of ‘normal’ childbirth is far from straightforward. It highlights a need to encourage women to view birth more positively. Expanding this research further would explore these issues in more detail, providing more conclusive evidence to support practice. thinking to happen, both parties need to agree on what a ‘normal’ birth actually is.
With these thoughts in mind, this research study set out to explore the understanding of normal birth held by women who have yet to experience birth, what influenced that understanding, and how closely their responses matched the range of definitions and ideas held by health professionals. Background Childbirth is multidimensional and requires a definition that covers all aspects (Downe, 2006). However, differences of meaning are in use by various professions, and none of the definitions truly encapsulate all aspects of childbirth or provide a consistent definition (Gould, 2000).
For some, childbirth without intervention is normal and optimal; for others, as long as the baby is born vaginally without assistance then this constitutes a normal birth. The term ‘normal childbirth’ has been used for decades as a way of differentiating between birth outcomes often for the purpose of producing statistical data. However, with continual scientific developments and an ever-changing society, the boundaries of what could be termed ‘normal’ have become blurred, particularly where interventions (and different degrees of interventions) are concerned.
The World Health Organization (WHO) (1996) defined normal birth as: ‘Spontaneous in onset, low risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously in the vertex position, between 37 and 42 completed weeks of pregnancy. After birth mother and infant are in good condition’. Conversely, however—and only a year later— Beech (1997) argued that: ‘ the expectation that every pregnancy should end in a healthy mother and baby no matter what, has actually encouraged the justification for use of interventions’.
British Journal of Midwifery • November 2011 • Vol 19, No 11 A Alison Edwards Senior Lecturer in Midwifery, Birmingham City University Jacky Conduit Lecturer in Nursing and Physiotherapy, University of Birmingham childbearing experience resulting in a healthy mother and baby is optimal. Finding agreement on the best way to achieve this, especially when considering the multifaceted nature of childbirth, is far more complex. Numerous articles and projects have shrouded childbirth in conflicting viewpoints and approaches, leaving even health professionals struggling to agree on a standard definition of normality.
Childbirth has increasingly become the focus of reality TV shows, often cleverly edited to portray childbirth in a more ‘entertaining’ way; or to fit a storyline as opposed to reality (Savage, 2006). Alongside this the internet has further provided women with a plethora of new perspectives on childbirth and has possibly influenced their perceptions. With an identified goal to reduce the number of caesarean sections and aim towards birth without intervention (Department of Health (DH), 2007), it could be argued that women should to be able to work alongside health professionals towards achieving this goal of ‘normality’.
It could also be suggested that to begin to enable this unity of 720 research The more recent consensus statement by the Maternity Care Working Party (MCWP) (2007), (which includes members of the National Childbirth Trust, ardent promoters of intervention-free birth), reflects some of the changes in their definition whereby some interventions such as augmentation of labour, the use of electronic monitoring and an active third stage, are acceptable. Interestingly, epidurals and episiotomy are excluded from the context of normality in this definition. A study by Downe et al (2001) also raised more questions than answers.
Their study raised the issue of ‘commonality’ as a factor in ‘normality’, i. e. whether the rise in the caesarean rate has led to this becoming considered as a ‘normal’ birth. In turn, they concluded that when establishing a percentage rate for normal births, by discounting women who experienced the use of any interventions such as induction and episiotomy, then the percentage of actual ‘normal’ births drops considerably. Downe et al (2001) and Duff (2002) also question the use of terms such as ‘according to rule’ or ‘commonplace’ in definitions, as a caesarean could now be considered commonplace but arguably not ‘normal’.
Gould (2000) and Crabtree (2008) concluded that some midwives considered birth to be normal if the woman saw it as normal; further developing the viewpoint that normality is individual to the woman and that every birth experience is unique. Anderson (2003) and McGuinness (2006) questioned the need for a definition at all and speculated about the impact of encouraging mothers to aim for normality, when the midwives themselves are not clear about what it is.
However, Anderson’s work is based primarily on the findings of one author and despite a convoluted journey through the literature, merely demonstrates how complex an issue normal childbirth has become. DeClercq et al (2005) reported on a substantial study of new mothers who were asked to describe their birth stories. The majority of the American ethnic minority women interviewed had experienced some degree of medical intervention. Although most felt that interference was not wanted or required, only 10% refused it.
Cronin and McCarthy (2003) explored the influences on women’s perceptions and concluded that the greatest influence came from family members. The sample used, however, consisted of predominantly teenage mothers, which may explain the reliance on the family for information. Phenomenological studies by Berg and Dahlberg (1998) and Gibbins and Thomson (2001), evaluated that the women they interviewed all felt that they wanted some control over their birth experiBritish Journal of Midwifery • November 2011 • Vol 19, No 11 nce but there were gaps in their knowledge which were usually filled by family members or information from the media. These studies of women just after birth or during pregnancy further demonstrated that women didn’t really consider some interventions to be a problem. What was clear in many of the studies, however, was that a positive birth experience led to higher satisfaction rates in the overall childbirth experience; conclusions supported by the comments found in a collection of births stories documented by McHugh (2001).
A few quantitative studies were found by Hundley et al (2001) and Sandin-Bojo et al (2008). Despite using alternative methodology, their findings supported the links between positive views of pregnancy, women’s preferences and the outcome, and the potential for inappropriate use of interventions. Having performed an extensive search using Cochrane, CINAHL and MEDLINE alongside primary and secondary references and seminal texts, the majority of available studies were conducted during the antenatal and postnatal period. No evidence was found which studied women’s perspectives before they became pregnant.
This study was therefore evolved to consider the aforementioned concepts and resulted in the research question, ‘Normal childbirth’: Do women’s definitions match those of health professionals? Study design The principal aim of the study was to explore the definitions of normal birth held by women who have yet to experience birth, what influences that perspective, and compare their views with those of health professionals. Objectives The main objectives of this study were to: l Gain insight into whether women who have yet to experience childbirth have similar definitions of normality o health professionals l Explore whether there is a need for improved education of women about childbirth l Gain insight into what influences these women’s perceptions of birth. As the main aim of this small explorative study was to explore women’s interpretation of ‘normal birth’, a qualitative approach was selected. A semistructured interview was selected as the means of collecting data, as this is well suited for the exploration of the perceptions and opinions of respondents especially with complex and sensitive issues. This approach also enables probing and clarification of responses to take place at the time of the interview itself.
This in turn enhances the validity of the find721 research ings (Parahoo, 1997). A semi-structured interview is particularly useful as it allow the participants to tell their own stories, in the way they choose, without the constraints of predetermined questions, as in a questionnaire (Rees, 2003). However, interviews can be time consuming, sometimes difficult to organize, and it can take time and practice to become an effective interviewer. description validity’ while maintaining rigour and trustworthiness (Savage, 2006), the interviews were audio-taped.
The discs were destroyed on completion of the study, but until then were stored securely. To maintain confidentiality, each participant was provided with a pseudonym from the outset and only the researcher was aware of the participant’s true identity. Prior to the interviews taking place the participants were provided with an information sheet, outlining the research project and were asked to sign a consent form. Relevant demographic details were also collected. Clarification regarding meeting of the inclusion criteria was sought prior to each interview. The intention was for the interviews to last for up to 40 minutes.
To aid focus and consistency, while providing room for flexibility, an interview schedule was drawn up using predominantly open-ended questions. A pilot run of the questions to be used was undertaken and any adjustments made before commencement of the study. This data was discarded and these participants were not involved in the study. The final open-ended questions included: l What has influenced the way you view childbirth? l How important would having a normal birth be to you? More probing questions were introduced as the interviews progressed, to develop the exploration of the individual issues raised by the participants.
A small ‘Thank you’ gift consisting of a gift voucher was given to each participant of the main study on completion of the interviews. To ensure validity and rigour (Flick, 2009) purposive sampling, an audit trail, interview schedule and tape-recorded interviews were used. Trustworthiness or credibility was maintained through continued contact and discussion of data with the participants to review the interpretation of the findings. Sampling Purposive sampling was used to ensure the participants met the inclusion criteria. Unlike quantitative research, with qualitative studies small samples are accepted as the norm (Higginbottom, 2004).
Inclusion criteria The criteria for inclusion in this study were for women to be of childbearing age between 18 and 45 years, not working in the field of health, and with no personal experience of pregnancy or childbirth. There were no restrictions on level of education, ethnicity, religion or culture. Those women who fell outside the age ranges or who had experienced any degree of childbirth including miscarriage would not be eligible to participate. Initial searches began with an email to female staff within the researcher’s workplace, i. e. an institute of higher education.
Initially there was limited response to the first request, but further searching led to a total of six women volunteering to participate. Two volunteers, however, did not fulfil the criteria and were therefore not interviewed. The four women fulfilling the inclusion criteria were working as administrative staff and were between the ages of 22 and 29 years. Three were in stable relationships, although not married, and the fourth was currently single. Levels of education ranged from A levels to Bachelor degrees. Three were white British and one participant was white Irish. None of them had any history of or personal experience of childbearing.
Time constraints unfortunately inhibited any further searches, which did lead to a limitation on the variety of women volunteering. The final group subsequently demonstrated a similar range of characteristics and demographics which may provide a more narrowed perspective. However, there is scope in future research to broaden the search to include women from other social backgrounds and ethnic groups. Ethical approval Ethical approval was sought from the research panel at the University and consent was obtained from line managers to approach staff and utilize the rooms for the interviews.
As the research did not involve patients and was not undertaken within NHS premises, further ethical approval was not required. The ethics panel granted permission to proceed provided the aforementioned actions regarding confidentiality were adhered to. It was made clear to all participants at the outset that they could withdraw from the study at any point and that if any of them were upset at any stage during the interview it would be stopped and British Journal of Midwifery • November 2011 • Vol 19, No 11
Semi-structured interviews In order to put the participants at ease the interviews took place in private, within the participant’s workplace and with a female researcher. To aid transcription of the data and avoid ‘compromising 722 research support offered. In this case none of the women expressed any concerns or demonstrated any signs of distress. Much of the previous literature concentrated on the definition of ‘normality’ being related to whether interventions were used within the labour.
Annabel felt that the definition of ‘normality’ had changed over the years but perceived that ‘commonality’ actually made birth normal. This perhaps contradicts Duff’s (2002) theory that terms such as ‘commonplace’ are not useful when defining normality. Annabel and Lucy both believed that if a lot of people used ‘gas and air’ for example, this made it the norm, but as epidurals were used less often they were not considered normal: ‘ … the epidural and not as many women use that—they don’t have that, except when they have complications. (Lucy) These responses to some extent demonstrated a perceived link between the use of more ‘significant’ interventions and a normal or otherwise outcome; thus agreeing with some of the MCWP (2007) definition and much of the current evidence. In an attempt to explore the respondents’ definition of normal birth in more depth, questions were asked about the difference between the terms ‘natural’ and ‘normal’. Reassuringly the responses reflected what many health professionals would consider a difference.
Annabel initially struggled to decide what the difference was, but then concluded that: ‘Natural would be not having all the drugs and what not … It’s very normal to have drugs and pain relief and all those sorts of things’. Or as Jane said: ‘I think a natural birth would be naturally having a baby without any drugs, doing it like the normal animal way without having some help. ’ The use of pain relief figured highly in all of the transcriptions but there was not a consensus on whether their use deemed a birth ‘normal’ or otherwise. Despite further probing, limited data were obtained on the use of other interventions apart from drugs.
Annabel and Victoria did suggest that having a forceps birth could be considered normal to them and indeed all of the participants expected to be in labour for a long time and have stitches, but other possible interventions were not mentioned. This may have been due to an expressed lack of knowledge about childbirth or British Journal of Midwifery • November 2011 • Vol 19, No 11 Analysis Once the interviews had been recorded and transcribed verbatim, a process of thematic analysis was used. Thematic analysis is a method for identifying, analyzing and reporting patterns (themes) within data.
It minimally organizes and describes the data set in (rich) detail (Braun and Clarke, 2006). Various techniques are described here but are based on the process of familiarization with the transcribed data and identifying patterns or themes occurring within it. These are then coded line-by-line to aid further analysis. As part of the researcher’s audit trail and to achieve greater validity of the findings, the researcher’s interpretations of the data was discussed with the individual participants and clarity sought where required following the interviews (Flick, 2009).
Findings Following analysis, three main themes emerged: birth without complications is normal, individual and important; birth is painful and scary; and the greatest source of knowledge is friends and family. Birth without complications is normal, individual and important When asked how they would define ‘normal’ birth, the women gave mixed and individual responses: ‘so a normal birth wouldn’t need any drugs or wouldn’t need any—what’s that help? … an epidural or anything like that to help you—you’ve had the baby and you’ve had no problems. (Jane) Victoria felt that it was acceptable to have an epidural and still have a normal birth. She supported the suggestion that birth is individual: ‘It’s quite confusing really, because natural is what I’d see as normal but in society today, normal doesn’t mean natural because caesareans are quite normal umm … to me all different types of childbirth are seen as normal. Every individual woman like—I know that for every individual woman no pregnancy is exactly the same so it is normal for some women to have a caesarean and some women not to and all different types of birth. 724 research due to the fact that they were not directly asked about it by the researcher in an effort to avoid influencing the responses. What did prove to be a significant concern for these individuals centred on having complicationfree labour rather than an intervention-free one. For example, when Annabel was asked what she would want from her birth experience, she spoke of: ‘… just sort of a generally easy birth without the complications and what not, the long long labour and things like that. Jane spoke along similar lines: ‘I think my idea is that as long as the baby comes out healthy and there’s been no problem then it’s been a normal birth’. She continued further later in the interview when asked how important normal birth was: ‘I think it would be really important because it’s a massive event so you want to have it set up in your mind that that’s the way I want to do it … if interventions have to happen you understand that these things have to come in. Jane stated her friends had been sharing their bad stories because they are ‘dramatic’; she was able to view the stories more objectively: ‘From the stories you hear about it being so painful but as well it being quite a nice experience and that you’ve got a child and you forget about all the pain. ’ Victoria had gained most of her information from the colleagues she worked with and felt that up until that point she knew very little about it; she reported that the stories she had heard ‘made me feel funny about it’.
All of the participants were asked to consider the impact the media and television had on their perception of childbirth. Perhaps reassuringly these participants recognized that the way childbirth is portrayed is often far from realistic and all felt that the greatest influences continued to be family and friends. This compares favourably with the work of Savage (2006). Other common threads ran through all of the interviews, including the need for the absence of complications and that it was the norm to give birth in hospital.
Both Jane and Victoria briefly mentioned home birth but would not consider it for themselves for fear of something going wrong. commented about their lack of knowledge about childbirth but when asked the source of their information, family and friends featured highly. Unfortunately, most of the stories the participants had heard were negative, further raising their anxieties about experiencing childbirth for themselves: ‘everyone that’s had a baby talks about it, it’s just not something I fancy doing at all—although some of my friends have had like the easiest birth ever, I tend to focus on the not-so-easy births and think ‘oh my god! hat would be me’. ’ (Annabel). Birth is painful and scary Not unexpectedly (although not directly asked about), all of the participants expressed fear of the unknown regarding childbirth, especially the degree of pain they expected to experience and the potential for, as Victoria expressed it, ‘to lose control’. Victoria also expressed a fear of her body and ‘how it works’ and how ‘it’s like a bit degrading’. In fact, none of the participants felt keen to undergo a pregnancy and birth for, as several expressed it, a ‘fear of something going wrong’.
On a more positive note, however, the majority saw pain as a necessity and that the outcome of a new baby made it worthwhile, as Jane surmised: ‘It’s meant to be from what I’ve heard one of the most painful things you can do in life but then at the end it’s worth it. ’ Discussion This study had an identified research question with clear objectives, principally to compare women’s views of normal childbirth with prevalent views of health professionals as reported in existing literature. Three distinct themes were identified which reflect some of the evidence available from studies with women who had already experienced childbirth.
Berg and Dahlberg (1998), for example evaluated that the women they interviewed all felt that they wanted some control over their birth experience but there were gaps in their knowledge which was filled usually by family members or British Journal of Midwifery • November 2011 • Vol 19, No 11 The greatest source of knowledge is friends and family This line of questioning resulted in the most discussion and volume of data produced. Throughout the interviews all of the participants repeatedly 726 research from reading in the media.
Also in 2001, Downe et al explored the concept of the use of interventions, including caesarean section, becoming ‘commonplace’ and therefore the norm. Indeed some of the participants in this study thought along similar lines If direct comparisons are made to definitions provided in the available literature, then to some degree we can conclude that the definitions of women and health professionals match. Some of the interventions listed in the MCWP’s definition matched those expected by the participants. However, formulating a distinction between ‘normal’ and otherwise proved less straightforward.
It is apparent that the women recognized childbirth as an individual concept, and that it was important to them to have a normal birth as they perceived it; studies by Gould (2000) and Crabtree (2008) reflect that health professionals widely acknowledge this. Perhaps controversially, it could be argued that the purpose of differentiating between types of birth lies with the generation of statistical data, supporting funding requests or even a professional need to justify one’s actions, rather than helping to achieve what appear to be the women’s aims of a healthy outcome irrespective of method.
Without seeking to encourage an increase in operative birth, perhaps removal of a definition of normality which excludes or includes specified interventions may go some way in helping to ease the pressure on women to conform to an ideal. Crabtree (2008) describes how in New Zealand, the use of interventions has markedly altered the definition of normal birth and while midwives make efforts to protect their women by for example, encouraging home visits to women in early labour, birth is becoming increasingly medicalized with interventions being the norm.
Clearly, achieving a birth without any interventions and complications is ideal, and midwives are trained to promote ‘normality’. However, the women who participated in this study feared the pain of childbirth and the possibility of any complications, such as a prolonged labour, far more than having any interventions such as an epidural or stitches. This is consistent with the conclusions drawn by Lawrence-Beech and Phipps (2008) that despite years of medicalization and increasing intervention, women’s hopes for a healthy baby and to feel ‘physically and mentally whole’ after the birth have remained consistent.
The 2007 report from the MCWP goes some way toward recognizing that a shift may be needed in thinking about the issue of common interventions and ‘normality’. More extensive research is needed to provide further clarification. British Journal of Midwifery • November 2011 • Vol 19, No 11 For these women who had no experience of childbirth, what proved to be a significant concern was having a complication-free labour rather than an intervention-free one.
Regarding the influences on women’s perceptions of normality, the majority of data indicated family and friends having the strongest influence. Unfortunately birth was often portrayed negatively which clearly discourages women. This perhaps presents a need to reconsider the approaches health professionals take when educating women about their ability to give birth. Reflection This was the researcher’s first attempt at utilizing this method of data collection and analysis and it is acknowledged that an effective interviewing technique takes time to develop.
Initially the interviewing technique was quite stilted and potentially important leads may have been missed. However, by utilizing the interview schedule as an aid, the latter interviews were much more relaxed and a greater degree of exploration of the points raised was enabled. As highlighted by Green and Thorogood (2004), we needed to consider potential ‘issues of bias due to the influence of the researcher, particularly when they are in the powerful position of health professional’.
To redress any imbalance of power and empower the participants to speak with ease (Holloway and Wheeler, 2002), the interviews were conducted within the participant’s workplace at a time convenient to them. There is also the possibility that the participants said what they thought the researcher wanted to hear (Rees, 2003). In this instance it was essential for the researcher to maintain a neutral stance during the interview. Only brief responses to 727 ISTOCKPHOTO research Key points Finding agreement on the best way to achieve a healthy birth can be complex l For health professionals to work with women to achieve the goal of ‘normality’ there needs to be agreement as to what a ‘normal’ birth is l In assessing what women thought about ‘normal’ birth, three main themes emerged: birth without complications is normal, individual and important; birth is painful and scary; and the greatest source of knowledge is friends and family l The results demonstrated an overall limited knowledge of childbirth among women, but, as with health professionals there was confusion as to what constitutes normality articipants’ direct questions were provided and leading questions were avoided. It is also inevitable that to some extent the interviewer’s knowledge and experience would influence the process and possibly the interpretation of the data. To minimize this impact the researcher aimed to ‘bracket’ out her own views until the interviews were completed. This involved suspending the researcher’s feelings while accepting that her own values will impact to some degree on the study (Lavender et al, 2004).
In this instance, however, the researcher’s knowledge proved beneficial during the interpretation process as it enabled direct comparison between a health professional’s view and that of the participant’s. Conclusions The findings of this small research project have only begun to scratch the surface of the initial enquiry. Much of the research undertaken prior to this was carried out on women who had experienced childbirth, therefore women who had yet to experience childbirth were selected for study.
The results demonstrated an overall limited knowledge of childbirth, but, as with health professionals the same confusion over what constitutes normality prevailed. The opportunity for more extensive research presents itself as this was a limited sample size. With a much larger sample clearer conclusions may be generated, providing greater supporting evidence for a rethink over what constiBJM tutes normality in today’s society. Anderson G (2003) A concept analysis of ‘normal birth’.
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