Background

An important prerequisite for optimal healthcare is a secure, safe and comfortable environment. There is little research on how the physical design of birthing rooms affects labour, birth, childbirth experiences and birthing costs. This protocol outlines the design of a randomised controlled superiority trial (RCT) measuring and comparing effects and experiences of two types of birthing rooms, conducted in one labour ward in Sweden.

Methods/design

Following ethics approval, a study design was developed and tested for feasibility in a pilot study, which led to some important improvements for conducting the study. The main RCT started January 2019 and includes nulliparous women presenting to the labour ward in active, spontaneous labour and who understand either Swedish, Arabic, Somali or English. Those who consent are randomised on a 1:1 ratio to receive care either in a regular room (control group) or in a newly built birthing room designed with a person-centred approach and physical aspects (such as light, silencer, media installation offering programmed nature scenes with sound, bathtub, birth support tools) that are changeable according to a woman’s wishes (intervention group). The primary efficacy endpoint is a composite score of four outcomes: no use of oxytocin for augmentation of labour; spontaneous vaginal births (i.e. no vaginal instrumental birth or caesarean section); normal postpartum blood loss (i.e. bleeding < 1000 ml); and a positive overall childbirth experience (7–10 on a scale of 1–10). To detect a difference in the composite score of 8% between the groups we need 1274 study participants (power of 80% with significance level 0.05). Secondary outcomes include: the four variables in the primary outcome; other physical outcomes of labour and birth; women’s self-reported experiences (the birthing room, childbirth, fear of childbirth, health-related quality of life); and measurement of costs in relation to the hospital stay for mother and neonate. Additionally, an ethnographic study with participant observations will be conducted in both types of birthing rooms.

Discussion

The findings aim to guide the design of birthing rooms that contribute to optimal quality of hospital-based maternity care.

Background: Despite evidence supporting the safety of vaginal birth after caesarean section (VBAC), rates are lowin many countries.

Methods: OptiBIRTH investigated the effects of a woman-centred intervention designed to increase VBAC ratesthrough an unblinded cluster randomised trial in 15 maternity units with VBAC rates < 35% in Germany, Ireland andItaly. Sites were matched in pairs or triplets based on annual birth numbers and VBAC rate, and randomised, 1:1 or 2:1, intervention versus control, following trial registration. The intervention involved evidence-based education ofclinicians and women with one previous caesarean section (CS), appointment of opinion leaders, audit/peer review,and joint discussions by women and clinicians. Control sites provided usual care. Primary outcome was annualhospital-level VBAC rates before the trial (2012) versus final year of the trial (2016). Between April 2014 and October2015, 2002 women were recruited (intervention 1195, control 807), with mode-of-birth data available for 1940women.

Results: The OptiBIRTH intervention was feasible and safe across hospital settings in three countries. There was nostatistically significant difference in the change in the proportion of women having a VBAC between interventionsites (25.6% in 2012 to 25.1% in 2016) and control sites (18.3 to 22.3%) (odds ratio adjusted for differences betweenintervention and control groups (2012) and for homogeneity in VBAC rates at sites in the countries: 0.87, 95% CI:0.67, 1.14, p = 0.32 based on 5674 women (2012) and 5284 (2016) with outcome data. Among recruited womenwith birth data, 4/1147 perinatal deaths > 24 weeks gestation occurred in the intervention group (0.34%) and 4/782in the control group (0.51%), and two uterine ruptures (one per group), a rate of 1:1000.

Conclusions: Changing clinical practice takes time. As elective repeat CS is the most common reason for CS inmultiparous women, interventions that are feasible and safe and that have been shown to lead to decreasingrepeat CS, should be promoted. Continued research to refine the best way of promoting VBAC is essential. Thismay best be done using an implementation science approach that can modify evidence-based interventions inresponse to changing clinical circumstances.Trial registration: The OptiBIRTH trial was registered on 3/4/2013. Trial registration number ISRCTN10612254.

Background: Women’s experiences of labour and birth can have both short- and long-term effects on theirphysical and psychological health. The original Swedish version of the Childbirth Experience Questionnaire (CEQ) has shown to have good psychometric quality and ability to differentiate between groups known to differ inchildbirth experience. Two subscales were revised in order to include new items with more relevant content aboutdecision-making and aspects of midwifery support. The aim of the study was to develop new items in twosubscales and to test construct validity and reliability of the revised version of CEQ, called CEQ2.

Method: A total of 11 new items (Professional Support and Participation) and 14 original items from the first CEQ(Own capacity and Perceived safety), were answered by 682 women with spontaneous onset of labour. Confirmatoryfactor analysis was used to analyse model fit.

Results: The hypothesised four-factor model showed good fit (CMIN = 2.79; RMR = 0.33; GFI = 0.94; CFI = 0.94; TLI =0.93; RMSEA = 0.054 and PCLOSE = 0.12) Cronbach’s alpha was good for all subscales (0.82, 0.83, 0.76 and 0.73) andfor the total scale (0.91).

Conclusions: CEQ2, like the first CEQ, yields four important aspects of experience during labour and birth showinggood psychometric performance, including decision-making and aspects of midwifery support, in both primiparousand multiparous women.

BACKGROUND: Labour and birth are sensitive physiological processes substantially influenced by environmental and psychosocial factors.

AIM: To explore the influence and meaning of the birth environment for nulliparous women giving birth in either one of two differently designed birthing rooms at a hospital-based labour ward.

METHODS: Five months of ethnographic fieldwork was conducted at a labour ward in Sweden, consisting of participant observations of 16 nulliparous women giving birth in either a 'Regular' birthing room (n = 8) or a specially designed, 'New room' (n = 8). Data included field notes, informal interviews, reflective notes, and individual interviews with eight women after birth. The data was analysed through an ethnographic iterative hermeneutic analysis process.

FINDINGS: The analysis identified the birth environment as consisting of the physical space, the human interaction within it, and the institutional context. The analytic concept; Birth Manual was conceived as an instrument for managing labour in accordance with institutional authority. Significant to the interpretation of the influence and meaning of the birth environment were two abstract rooms: an Institutional room, where birth was approached as a critical event, designating birthing women as passive; and a Personal room, where birth was approached as a physiological event in which women's agency was facilitated.

CONCLUSION: Institutional authority permeated the atmosphere within the birth environment, irrespective of the design of the room. A power imbalance between institutional demands and birthing women's needs was identified, emphasising the vital role the birth philosophy plays in creating safe birth environments that increase women's sense of agency.

To investigate the prevalence of childbirth-related fear from pregnancy to one year after childbirth and to identify factors associated with being cured of childbirth-related fear. Design A longitudinal regional survey. Setting Three hospitals in a northern part of Sweden. Participants Six hundred ninety-seven (697) women who completed four questionnaires. Methods Data were collected by questionnaires in mid and late pregnancy and at 2 months and one year after birth. Childbirth related fear was measured 3 times. Results There was a statistically significant increase in childbirth fear from 12.4% in mid-pregnancy to 15.1% one year after childbirth (p < .001). Women who were cured of childbirth fear reported a better birth experience and would prefer a vaginal birth in a subsequent pregnancy. These women were also more likely to experience a feeling of control during birth and were more satisfied with information about the progress of labor, but there was no difference in prenatal counseling or having an elective cesarean between the groups. Conclusion Women with prenatal fear of childbirth may be cured of this fear by having a better birth experience. If women feel in control of their bodies and are well informed about the progress of labor, the chances of being cured will increase. Prenatal counseling or having an elective cesarean birth does not seem to be a solution for relieving childbirth fear.

BACKGROUND: The second stage of labour is generally considered as an intensive part of labour. Despite this, knowledge about women's experiences of the second stage of labour is scant.

AIM: To explore experiences of the second stage of labour in women with spontaneous vaginal birth.

METHODS: This is a qualitative study where twenty-one women with a spontaneous birth at term, were interviewed four to ten weeks after birth. Data were analysed using qualitative thematic analysis based on descriptive phenomenology. The participating women had experienced a vaginal birth; some for the first time, having previously given birth by caesarean section and some with a previous vaginal birth.

FINDINGS: Three themes emerged: "An experience of upheaval" which represents the women's experiences of intensity, power and pain during the second stage of labour. "The importance of trusting relationships" signifies the meaning of women's relationships during the second stage of labour. "Becoming a mother" which is characterised by feelings of accomplishment and the experience of the final moments of birth.

CONCLUSION: During the second stage of labour women experienced overwhelming sensations which made evident the importance of trusting relationships with those involved in the birth. The women were in a transformative state between pregnancy and motherhood where experiences of being involved and being provided with information and guidance were all considered crucial. Continuous support should be offered to women during the second stage of labour.

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.

Background

Theoretical models as a basis for midwives’ care have been developed over recent decades. Although there are similarities between these models, their usefulness in practice needs to be researched in specific cultural contexts.

Aim

To explore whether, when adopted by midwives on labour wards, a midwifery model of woman-centred care (MiMo) was useful in practice from the viewpoint of a variety of health professionals.

Methods

Data were collected from a variety of health professionals before and after an intervention of implementating MiMo at a hospital-based labour ward in Sweden, using nine focus group interviews with a total of 43 participants: midwives (n = 16), obstetricians (n = 8), assistant nurses (n = 11) and managers (n = 8). The text from interviews was analysed using content analysis.

Findings

From expressing no explicit need of a midwifery model of woman-centred care before the intervention, there was a shift in midwives, obstetricians and managers perceptions towards identifying advantages of using the MiMo as it gives words to woman-centred midwifery care. Such shift in perception was not found among the assistant nurses.

Discussion

Clarification of the various roles of health professionals is needed to develop the model. Heavy workloads and stress were barriers to implementing the model. Thus, more support is needed from organisational management.

Conclusions

The model was useful for all professional groups, except for assistant nurses. Further studies are needed in order to clarify the various professional roles and interdisciplinary collaborations in making the MiMo more useful in daily maternity care.

BACKGROUND: Caesarean section (CS) rates are increasing worldwide and the most common reason is repeat CS following previous CS. For most women a vaginal birth after a previous CS (VBAC) is a safe option. However, the rate of VBAC differs in an international perspective. Obtaining deeper knowledge of clinicians' views on VBAC can help in understanding the factors of importance for increasing VBAC rates. Focus group interviews with clinicians and women in three countries with high VBAC rates (Finland, Sweden and the Netherlands) and three countries with low VBAC rates (Ireland, Italy and Germany) are part of "OptiBIRTH", an ongoing research project. The study reported here aims to explore the views of clinicians from countries with low VBAC rates on factors of importance for improving VBAC rates.

METHODS: Focus group interviews were held in Ireland, Italy and Germany. In total 71 clinicians participated in nine focus group interviews. Five central questions about VBAC were used and interviews were analysed using content analysis. The analysis was performed in each country in the native language and then translated into English. All data were then analysed together and final categories were validated in each country.

RESULTS: The findings are presented in four main categories with several sub-categories: 1) "prameters for VBAC", including the importance of the obstetric history, present obstetric factors, a positive attitude among those who are centrally involved, early follow-up after CS and antenatal classes; 2) "organisational support and resources for women undergoing a VBAC", meaning a successful VBAC requires clinical expertise and resources during labour; 3) "fear as a key inhibitor of successful VBAC", including understanding women's fear of childbirth, clinicians' fear of VBAC and the ways that clinicians' fear can be transferred to women; and 4) "shared decision making - rapport, knowledge and confidence", meaning ensuring consistent, realistic and unbiased information and developing trust within the clinician-woman relationship.

CONCLUSIONS: The findings indicate that increasing the VBAC rate depends on organisational factors, the care offered during pregnancy and childbirth, the decision-making process and the strategies employed to reduce fear in all involved.

BACKGROUND: The number of caesarean sections (CS) is increasing globally, and repeat CS after a previous CS is a significant contributor to the overall CS rate. Vaginal birth after caesarean (VBAC) can be seen as a real and viable option for most women with previous CS. To achieve success, however, women need the support of their clinicians (obstetricians and midwives). The aim of this study was to evaluate clinician-centred interventions designed to increase the rate of VBAC.

METHODS: The bibliographic databases of The Cochrane Library, PubMed, PsychINFO and CINAHL were searched for randomised controlled trials, including cluster randomised trials that evaluated the effectiveness of any intervention targeted directly at clinicians aimed at increasing VBAC rates. Included studies were appraised independently by two reviewers. Data were extracted independently by three reviewers. The quality of the included studies was assessed using the quality assessment tool, 'Effective Public Health Practice Project'. The primary outcome measure was VBAC rates.

RESULTS: 238 citations were screened, 255 were excluded by title and abstract. 11 full-text papers were reviewed; eight were excluded, resulting in three included papers. One study evaluated the effectiveness of antepartum x-ray pelvimetry (XRP) in 306 women with one previous CS. One study evaluated the effects of external peer review on CS birth in 45 hospitals, and the third evaluated opinion leader education and audit and feedback in 16 hospitals. The use of external peer review, audit and feedback had no significant effect on VBAC rates. An educational strategy delivered by an opinion leader significantly increased VBAC rates. The use of XRP significantly increased CS rates.

CONCLUSIONS: This systematic review indicates that few studies have evaluated the effects of clinician-centred interventions on VBAC rates, and interventions are of varying types which limited the ability to meta-analyse data. A further limitation is that the included studies were performed during the late 1980s-1990s. An opinion leader educational strategy confers benefit for increasing VBAC rates. This strategy should be further studied in different maternity care settings and with professionals other than physicians only.

BACKGROUND: The most common reason for caesarean section (CS) is repeat CS following previous CS. Vaginal birth after caesarean section (VBAC) rates vary widely in different healthcare settings and countries. Obtaining deeper knowledge of clinicians' views on VBAC can help in understanding the factors of importance for increasing VBAC rates. Interview studies with clinicians and women in three countries with high VBAC rates (Finland, Sweden and the Netherlands) and three countries with low VBAC rates (Ireland, Italy and Germany) are part of 'OptiBIRTH', an ongoing research project. The study reported here is based on interviews in high VBAC countries. The aim of the study was to investigate the views of clinicians working in countries with high VBAC rates on factors of importance for improving VBAC rates.

METHODS: Individual (face-to-face or telephone) interviews and focus group interviews with clinicians (in different maternity care settings) in three countries with high VBAC rates were conducted during 2012-2013. In total, 44 clinicians participated: 26 midwives and 18 obstetricians. Five central questions about VBAC were used and interviews were analysed using content analysis. The analysis was performed in each country in the native language and then translated into English. All data were then analysed together and final categories were validated in each country.

RESULTS: The findings are presented in four main categories with subcategories. First, a common approach is needed, including: feeling confident with VBAC, considering VBAC as the first alternative, communicating well, working in a team, working in accordance with a model and making agreements with the woman. Second, obstetricians need to make the final decision on the mode of delivery while involving women in counselling towards VBAC. Third, a woman who has a previous CS has a similar need for support as other labouring women, but with some extra precautions and additional recommendations for her care. Finally, clinicians should help strengthen women's trust in VBAC, including building their trust in giving birth vaginally, recognising that giving birth naturally is an empowering experience for women, alleviating fear and offering extra visits to discuss the previous CS, and joining with the woman in a dialogue while leaving the decision about the mode of birth open.

CONCLUSIONS: This study shows that, according to midwives and obstetricians from countries with high VBAC rates, the important factors for improving the VBAC rate are related to the structure of the maternity care system in the country, to the cooperation between midwives and obstetricians, and to the care offered during pregnancy and birth. More research on clinicians' perspectives is needed from countries with low, as well as high, VBAC rates.

Purpose: There is a need to gain deeper knowledge about women’s experience of vaginal birth after caesarean section (VBAC). Considerable research has been conducted on VBAC; however, only a few qualitative studies focus on women’s experiences. Therefore, the aim of this study was to describe the lived experiences of VBAC among women resident in Sweden, a country with a high VBAC rate.

Method: This studywas performed in accordance with a phenomenological reflective lifeworld approach. Interviews were conducted with nine women in an urban region of Sweden one year after their VBAC birth.

Results: The essential meaning of the studied phenomenon is “to challenge oneself as a childbearing woman”, which is further described by its four constituents: “striving for support from professionals”, “desiring the experience”, “contrasting and comparing memories of two different births” and “being part of the birthing culture”.

Conclusions: The experience of VBAC meant regained trust in the ability to give birth vaginally. The women lacked follow-up and support after the caesarean section (CS), during the subsequent pregnancy and the forthcoming VBAC. Enhanced support could be a key factor in helping women meeting the challenge and feel confident about giving birth vaginally despite their previous experiences of CS.

Objective: To describe the meaning of previous experiences of childbirth in pregnant women who have exhibited intense fear of childbirth such that it has an impact on their daily lives.

Design: A descriptive phenomenological study. Setting: A maternity clinic for women with fear of childbirth in the western part of Sweden. Participants: Nine women with intense fear of childbirth who were pregnant with their second child and considered their previous birth experiences negative.

Methods: Interviews that were transcribed verbatim and analyzed with a reflective life-world approach.

Results: The essential meanings that emerged were a sense of not being present in the delivery room and an incomplete childbirth experience. The women felt as if they had no place there, that they were unable to take their place, and that even if the midwife was present, she did not provide support. The experience remained etched in the women’s minds and gave rise to feelings of fear, loneliness, and lack of faith in their ability to give birth and diminished trust in maternity care. These experiences contrasted with brief moments that made sense.

Conclusions: Previous childbirth experiences for pregnant women with intense fear of childbirth have a deep influence and can be related to suffering and birth trauma. The implication is to provide maternity care where the nurse/ midwife is present and supports women during birth in a way that enables them to be present and take their place during birth.

OBJECTIVE: To describe the meaning of previous experiences of childbirth in pregnant women who have exhibited intense fear of childbirth such that it has an impact on their daily lives. DESIGN: A descriptive phenomenological study. SETTING: A maternity clinic for women with fear of childbirth in the western part of Sweden. PARTICIPANTS: Nine women with intense fear of childbirth who were pregnant with their second child and considered their previous birth experiences negative. METHODS: Interviews that were transcribed verbatim and analyzed with a reflective life-world approach. RESULTS: The essential meanings that emerged were a sense of not being present in the delivery room and an incomplete childbirth experience. The women felt as if they had no place there, that they were unable to take their place, and that even if the midwife was present, she did not provide support. The experience remained etched in the women's minds and gave rise to feelings of fear, loneliness, and lack of faith in their ability to give birth and diminished trust in maternity care. These experiences contrasted with brief moments that made sense. CONCLUSIONS: Previous childbirth experiences for pregnant women with intense fear of childbirth have a deep influence and can be related to suffering and birth trauma. The implication is to provide maternity care where the nurse/midwife is present and supports women during birth in a way that enables them to be present and take their place during birth.

PROBLEM:

Fear of childbirth negatively affects women during pregnancy and after birth.

AIM:

To summarise the findings of published studies regarding possible causes/predisposing factors and outcomes of fear of childbirth for childbearing women.

DESIGN:

A systematic review, searching five databases in March 2015 for studies on causes/predisposing factors and outcomes of fear of childbirth, as measured during pregnancy and postpartum. Quality of included studies was assessed independently by pairs of authors. Data were extracted independently by reviewer pairs and described in a narrative analysis.

FINDINGS:

Cross-sectional, register-based and case-control studies were included (n=21). Causes were grouped into population characteristics, mood-related aspects, and pregnancy and birth-related aspects. Outcomes were defined as mood-related or pregnancy and birth-related aspects. Differing definitions of fear of childbirth were found and meta-analysis could only be performed on parity, in a few studies.

CONCLUSIONS:

Stress, anxiety, depression and lack of social support are associated with fear during pregnancy. Need for psychiatric care and presence of traumatic stress symptoms are reported outcomes together with prolonged labour, longer labours, use of epidural and obstetric complications. Nulliparous and parous women have similar levels of fear but for different reasons. Since the strongest predictor for fear in parous women is a previous negative birth experience or operative birth, we suggest it is important to distinguish between fear of childbirth and fear after birth. Findings demonstrate the need for creating woman-centred birthing environments where women can feel free and secure with low risk of negative or traumatic birth experiences and consequent fear.

Background

Fear of Childbirth (FOC) is a common problem affecting women’s health and wellbeing, and a common reason for requesting caesarean section. The aims of this review were to summarise published research on prevalence of FOC in childbearing women and how it is defined and measured during pregnancy and postpartum, and to search for useful measures of FOC, for research as well as for clinical settings.

Methods

Five bibliographic databases in March 2015 were searched for published research on FOC, using a protocol agreed a priori. The quality of selected studies was assessed independently by pairs of authors. Prevalence data, definitions and methods of measurement were extracted independently from each included study by pairs of authors. Finally, some of the country rates were combined and compared.

Results

In total, 12,188 citations were identified and screened by title and abstract; 11,698 were excluded and full-text of 490 assessed for analysis. Of these, 466 were excluded leaving 24 papers included in the review, presenting prevalence of FOC from nine countries in Europe, Australia, Canada and the United States. Various definitions and measurements of FOC were used. The most frequently-used scale was the W-DEQ with various cut-off points describing moderate, severe/intense and extreme/phobic fear. Different 3-, 4-, and 5/6 point scales and visual analogue scales were also used. Country rates (as measured by seven studies using W-DEQ with ≥85 cut-off point) varied from 6.3 to 14.8%, a significant difference (chi-square = 104.44, d.f. = 6, p < 0.0001).

Conclusions

Rates of severe FOC, measured in the same way, varied in different countries. Reasons why FOC might differ are unknown, and further research is necessary. Future studies on FOC should use the W-DEQ tool with a cut-off point of ≥85, or a more thoroughly tested version of the FOBS scale, or a three-point scale measurement of FOC using a single question as ‘Are you afraid about the birth?’ In this way, valid comparisons in research can be made. Moreover, validation of a clinical tool that is more focussed on FOC alone, and easier than the longer W-DEQ, for women to fill in and clinicians to administer, is required.

PROBLEM AND BACKGROUND:Vaginal birth after caesarean section is a safe option for the majority of women. Seeking women's views can be of help in understanding factors of importance for achieving vaginal birth in countries where the vaginal birth rates after caesarean is low.AIM:To investigate women's views on important factors to improve the rate of vaginal birth after caesareanin countries where vaginal birth rates after previous caesarean are low.

METHODS:A qualitative study using content analysis. Data were gathered through focus groups and individual interviews with 51 women, in their native languages, in Germany, Ireland and Italy. The women were asked five questions about vaginal birth after caesarean. Data were translated to English, analysed together and finally validated in each country.

FINDINGS:Important factors for the women were that all involved in caring for them were of the same opinion about vaginal birth after caesarean, that they experience shared decision-making with clinicians supportive of vaginal birth, receive correct information, are sufficiently prepared for a vaginal birth, and experience a culture that supports vaginal birth after caesarean.DISCUSSION AND

CONCLUSION:Women's decision-making about vaginal birth after caesarean in these countries involves a complex, multidimensional interplay of medical, psychosocial, cultural, personal and practical considerations. Further research is needed to explore if the information deficit women report negatively affects their ability to make informed choices, and to understand what matters most to women when making decisions about vaginal birth after a previous caesarean as a mode of birth.

Objective: To explore fear of childbirth (FOC) during pregnancy and one year after birth and its association to birth experience and mode of delivery. Design: A longitudinal population-based study. Population: Pregnant women who were listed for a routine ultrasound at three hospitals in the middle-north part of Sweden. Method: Differences between women who reported FOC and who did not were calculated using risk ratios with a 95% confidence interval. In order to explain which factors were most strongly associated to suffer from FOC during pregnancy and one year after childbirth, multivariate logistic regression analyses were used. Results: FOC during pregnancy in multiparous women was associated with a previous negative birth experience (RR 5.1, CI 2.5—10.4) and a previous emergency caesarean section (RR 2.5, CI 1.2—5.4). Associated factors for FOC one year after childbirth were: a negative birth experience (RR 10.3, CI 5.1—20.7), fear of childbirth during pregnancy (RR 7.1, CI 4.4—11.7), emergency caesarean section (RR 2.4, CI 1.2—4.5) and primiparity (RR 1.9, CI 1.2—3.1). Conclusion: FOC was associated with negative birth experiences. Women still perceived the birth experience as negative a year after the event. Women’s perception of the overall birth experience as negative seems to be more important for explaining subsequent FOC than mode of delivery. Maternity care should focus on women’s experiences of childbirth. Staff at antenatal clinics should ask multiparous women about their previous experience of childbirth. So that FOC is minimized, research on factors that create a positive birth experience for women is required.

OBJECTIVE: to describe women's lived experience of fear of childbirth.

DESIGN: a qualitative study using a phenomenological approach and a lifeworld perspective. Data were collected via tape-recorded interviews. SETTING: Sahlgrenska University Hospital, Göteborg, Sweden in 2003. PARTICIPANTS: eight pregnant women (24-37 gestational weeks) seeking help within an outpatient clinic for women with severe fear of childbirth. Two of the women were primiparous.

FINDINGS: four constituents were identified: feeling of danger that threatens and appeals; feeling trapped; feeling like an inferior mother-to-be and on your own. The essential structure was described as 'to lose oneself as a woman into loneliness'.

KEY CONCLUSIONS: fear of childbirth affects women in such a way that they start to doubt themselves and feel uncertain of their ability to bear and give birth to a child. Previous birth experience was central to the multiparous women. They described their experiences of suffering in relation to the care they received during childbirth. This mainly concerned pain and negative experiences with staff.

IMPLICATIONS FOR PRACTICE: pregnant women who fear childbirth are an exposed group in need of much support during pregnancy and childbirth. The encounter between the woman and the midwife can be a way of breaking down the feeling of loneliness and restoring the woman's trust in herself as a childbearing woman.

OBJECTIVE: to evaluate the effectiveness of women-centred interventions during pregnancy and birth to increase rates of vaginal birth after caesarean.

DESIGN: we searched bibliographic databases for randomised trials or cluster randomised trials on women-centred interventions during pregnancy and birth designed to increase VBAC rates in women with at least one previous caesarean section. Comparator groups included standard or usual care or an alternative treatment aimed at increasing VBAC rates. The methodological quality of included studies was assessed independently by two authors using the Effective Public Health Practice Project quality assessment tool. Outcome data were extracted independently from each included study by two review authors.

FINDINGS: in total, 821 citations were identified and screened by title and abstract; 806 were excluded and full text of 15 assessed. Of these, 12 were excluded leaving three papers included in the review. Two studies evaluated the effectiveness of decision aids for mode of birth and one evaluated the effectiveness of an antenatal education programme. The findings demonstrate that neither the use of decision aids nor information/education of women have a significant effect on VBAC rates. Nevertheless, decision-aids significantly decrease women's decisional conflict about mode of birth, and information programmes significantly increase their knowledge about the risks and benefits of possible modes of birth.

KEY CONCLUSIONS: few studies evaluated women-centred interventions designed to improve VBAC rates, and all interventions were applied in pregnancy only, none during the birth. There is an urgent need to develop and evaluate the effectiveness of all types of women-centred interventions during pregnancy and birth, designed to improve VBAC rates.

IMPLICATIONS FOR PRACTICE: decision-aids and information programmes during pregnancy should be provided for women as, even though they do not affect the rate of VBAC, they decrease women's decisional conflict and increase their knowledge about possible modes of birth.

Purpose: There is a need to deepen knowledge about midwives’ care in obstetric-led labour wards in which midwives are responsible for normal births. This ethnographic study explores the content and meaning of midwives’ care of women in a hospital-based labour ward in Sweden prior to the introduction of a theoretical midwifery model of care. 

Methods: Data were gathered through participant observation, analysed through interpretation grounded in reflexivity discussions and are presented in the form of ethnographic descriptions. 

Results: The midwives’ care was provided in a field of tension in which they had to balance contrasting models of care, described in the themes: The birthing rooms and the office—Different rooms of care, Women giving birth or being delivered—Midwives’ expectations and relationships with women, Old and new caring roles of the midwife—Women giving birth in a “new age”, Being and doing—Different approaches to caring, and Holistic and reductionist care—Guided by contrasting models and guidelines. The midwives’ freedom to act as autonomous professionals was hindered by medical and institutional models of care and this led to uncertainty regarding their roles as midwives. 

Conclusions: Midwives having to balance their activities in a field of tension require midwifery models that can guide their practice.

Despite the consequences for women’s health, a repeat cesarean section (CS) birth after a previous CS is common in Western countries. Vaginal Birth After Cesarean (VBAC) is recommended for most women, yet VBAC rates are decreasing and vary across maternity organizations and countries. We investigated women’s views on factors of importance for improving the rate of VBAC in countries where VBAC rates are high. We interviewed 22 women who had experienced VBAC in Finland, the Netherlands, and Sweden. We used content analysis, which revealed five categories: receiving information from supportive clinicians, receiving professional support from a calm and confident midwife/obstetrician during childbirth, knowing the advantages of VBAC, letting go of the previous childbirth in preparation for the new birth, and viewing VBAC as the first alternative for all involved when no complications are present. These findings reflect not only women’s needs but also sociocultural factors influencing their views on VBAC.

Aim: To summarize, categorize and describe published research on how birthing room design influences maternal and neonate physical and emotional outcomes.

Background: The physical healthcare environment has significant effects on health and wellbeing. Research indicates that birthing environments can impact women during labor and birth. However, summaries of the effects of different environments around birth are scarce.

Methods: We conducted a systematic review, searching 10 databases in 2016 and 2017 for published research from their inception dates, on how birthing room design influences maternal and neonate physical and emotional outcomes, using a protocol agreed a priori. The quality of selected studies was assessed, and data were extracted independently by pairs of authors and described in a narrative analysis.

Results: In total, 3373 records were identified and screened by title and abstract; 2063 were excluded and the full text of 278 assessed for analysis. Another 241 were excluded, leaving 15 articles presenting qualitative and quantitative data from six different countries on four continents. The results of the analysis reveal four prominent physical themes in birthing rooms that positively influence on maternal and neonate physical and emotional outcomes: 1) means of distraction, comfort, and relaxation; 2) raising the birthing room temperature; 3) features of familiarity; and 4) diminishing a technocratic environment.

Conclusions: The evidence on how birthing environments affect outcomes of labor and birth is incomplete. There is a crucial need for more research in this field.    

Aim: The aim of this paper was to discuss how to understand and undertake thematic analysis based on descriptive phenomenology. Methodological principles to guide the process of analysis are offered grounded on phenomenological philosophy. This is further discussed in relation to how scientific rigour and validity can be achieved.

Design: This is a discursive article on thematic analysis based on descriptive phenomenology.

Results: This paper takes thematic analysis based on a descriptive phenomenological tradition forward and provides a useful description on how to undertake the analysis. Ontological and epistemological foundations of descriptive phenomenology are outlined. Methodological principles are explained to guide the process of analysis, as well as help to understand validity and rigour. Researchers and students in nursing and midwifery conducting qualitative research need comprehensible and valid methods to analyse the meaning of lived experiences and organize data in meaningful ways.

The improvement of mental healthcare services requires patients' experiences to identify problems and possible deficits in care. In this study, we explored the nature and meaning of formal patient complaints about mental healthcare services in one region of Sweden using a descriptive design with a qualitative approach. A systematic random sample of 106 formal patient complaints about mental healthcare services in 1 Swedish county was selected and analysed thematically, based on descriptive phenomenology. Themes identified were: lack of access to mental healthcare services and specialist treatment, problems related to unmet needs and difficulties with healthcare staff, insufficient care and treatment and lack of continuity in care, and experiences of not been taken seriously or feeling abused by staff. The vulnerability of patients already in the system is a greater issue than realized. The human right to health and the healthcare of patients with mental ill health can be strengthened by increased access to care, listening to patients properly, and delivering continuity in care.

Purpose: Women’s experiences of pregnancy, labour and birth are for some pregnant women negative and they develop a fear of childbirth, which can have consequences for their wellbeing and health. The aim was to synthesize qualitative literature to deepen the understanding of women’s experiences of fear of childbirth.

Methods: A systematic literature search and a meta-synthesis that included 14 qualitative papers.

Results: The main results demonstrate a deepened understanding of women’s experiences of fear of childbirth interpreted through the metaphor “being at a point of no return”. Being at this point meant that the women thought there was no turning back from their situation, further described in the three themes: To suffer consequences from traumatic births, To lack warranty and understanding, and To face the fear.

Conclusions: Women with fear of childbirth are need of support that can meet their existential issues about being at this point of no return, allowing them to express and integrate their feelings, experiences and expectations during pregnancy, childbirth and after birth.

Women with fear after birth, i.e., after an earlier negative birth experience, need support that enables them to regain trust in maternity care professionals and their willingness to provide them with good care that offers the support that individual women require. Women pregnant for the first time require similar support to reassure them that other’s experiences will not happen to them.

Objective

Fear of childbirth is a well-known problem affecting women’s wellbeing and health. The prevalence of intense fear varies across countries from 4.8 to 14.8%. During the past 25 years in Sweden women with intense fear of childbirth have been offered counselling at specialised clinics staffed by midwives. Although the counselling demonstrates positive results, the training, education, supervision and organisation differ between clinics. It is still unclear which approaches and practices are the most beneficial. The aim was to explore and describe the counselling of women with intense fear of childbirth from the viewpoint of midwives who provide counselling in specialised fear of childbirth clinics in one region of Sweden.

Methods

A qualitative study of 13 midwives using focus group interviews and inductive content analysis.

Results

The midwives’ counselling of women with intense fear of childbirth is described as ‘striving to create a safe place for exploring fear of childbirth’, comprising the following categories: Providing a reliable relationship; Investigating previous and present fears; and A strong dedication to the women.

Conclusion

Although there are no guidelines for the counselling the midwives described similar frameworks. Some approaches were general, while others were specific and related to the individual woman’s parity. The midwives achieved professional and personal development through counselling experiences. The findings add to the existing literature on counselling and can be used to inform the development of midwife-led interventions for women with intense fear of childbirth and previous traumatic births, as well as for the formal education of midwives.