Coping With the Unexpected in Childbirth: A Thematic Analysis

Abstract

This article reports original research that describes new mothers' experiences of birth and maternity care. Qualitative data were collected through a survey on birth satisfaction, which included space for women to provide comments about their birth and experience of care. Thirty-nine women provided comments that were analyzed using the thematic analysis method. Two themes emerged from the women's experiences: “Unexpected birth processes: expectations and reality” and “Coping with birth: the role of health-care staff.” Participants described unexpected birthing processes, their experiences of care, and maternity care staff's contributions to coping with birth. Implications for practice for childbirth professionals include promotion of physiologic birth, respectful person-centered care during all phases of perinatal care, and the value of childbirth preparation.

INTRODUCTION

Care during childbirth occupies a critical position in health care and provides the foundation for healthy communities. The United States spends more on childbirth care than other countries yet continues to have worse outcomes than other high-resource countries, with more maternal and infant deaths, illness, and injury. Some women in the United States also feel there is a significant gap in care they receive and the care they expect. In response to these pervasive issues in the maternity care system in the United States, The National Academies of Sciences, Engineering, and Medicine (NASEM, 2020) convened a group of childbirth experts and generated a landmark report identifying ways in which investing in our maternity care system can make birth safer and healthier for families than it is today. The pillars of these recommendations include respectful treatment, risk assessment, informed choice, and shared decision-making, the right amount of care at the right time, and strengthening the maternity care workforce.

The Institute for Healthcare Improvement (IHI, 2020) has worked for the past two decades to improve the experience of care for childbearing families in the United States. This work has centered around the triple aim for health care, which encompasses health of populations, patient experience, and cost. Recently, the work of the IHI, regarding maternity care, has focused on the theme of “keeping normal,” which refers dually to a woman's body's ability to achieve the “normal” event of childbirth and to minimize the interventions which have become “normalized” in current times. To achieve the high-quality maternity care described in the triple aim, it is essential that the consumers of this care, childbearing women, have a positive experience of care. The purpose of this study is to explore the experiences of birth and maternity care from the perspective of childbearing women in a maternity setting.

LITERATURE REVIEW

Becoming a mother is a major milestone in a woman's life and childbirth marks the beginning of this significant life change. Women and families today have access to many different sources of information that shape their perceptions, expectations, and knowledge of the birth process. Some of the sources of information mothers report using to prepare for birth include family and friends, the Internet, and formal childbirth preparation programs (Hinic, 2017; Weatherspoon et al., 2015). From these sources, women formulate hopes and expectations for how the birth process may look for them including type of birth, method of pain management, and involvement of support persons and partners. A woman's subjective experience of childbirth and the degree to which it diverges from what had been anticipated has the potential to affect early maternal parenting behaviors (Bell et al., 2018; Bell et al., 2019; Hinic, 2016) and the mother's short and long-term psychological well-being (Bell & Andersson, 2016). Negative birth experiences have been associated with development of postpartum depression (PPD) (Bell & Andersson, 2016; Kountanis et al., 2020), symptoms of post-traumatic stress (Ayers et al., 2016; Kountanis et al., 2020), feelings of failure and inability to connect emotionally with their infant (Fenech & Thompson, 2014), and fear associated with future pregnancies (Baxter, 2020).

Birth satisfaction is a multidimensional construct defined as a retrospective maternal evaluation of the labor experience (Hollins Martin & Fleming, 2011) and is influenced by several key factors including quality of care, maternal personal attributes, and stress experienced during labor (Hollins Martin & Fleming, 2011; Hollins Martin et al., 2020). Early maternal–newborn contact (Brubaker et al., 2018) and secure adult attachment (Reisz et al., 2019) have also been associated with positive birth experience. While maternal personal attributes such as personality, coping skills, and attachment will likely be well-established in the childbearing woman, perinatal care providers have many opportunities to positively influence childbirth satisfaction through providing quality care, mitigating stress, and promoting a sense of control for the childbearing woman during labor and birth.

METHODS

Primary Study

The primary research method used in this study was a survey that explored the relationships among birth satisfaction, perceived stress, and breastfeeding self-efficacy in a convenience sample of primarily White-non-Hispanic women (N = 107) in a single regional perinatal center in the Mid-Atlantic Region of the United States during the first 4 days postpartum. The Birth Satisfaction Scale-Revised (BSS-R) (Hollins Martin & Martin, 2014) contains 10 items scored on a five-point Likert scale, based on participants' agreement with each statement and measures the multifaceted construct of birth satisfaction in a way that would allow health-care professionals to measure maternal perceptions of intrapartum quality of care and childbirth experience. In addition to eliciting quantitative feedback, the BSS-R includes space after each question for the woman to add subjective comments related to the birth experience. See Figure 1 for items included on BSS-R.

Figure 1. Birth Satisfaction Scale-Revised information.

I came through childbirth virtually unscathed I thought my labour was excessively long The delivery room staff encouraged me to make decisions about how I wanted my birth to progress I felt very anxious during my labour and birth I felt well supported by staff during my labour and birth The staff communicated well with me during labour I found giving birth a distressing experience I felt out of control during my birth experience I was not distressed at all during labour The delivery room was clean and hygienic Participants respond on a five-point Likert scale based on level of agreement/disagreement with each of the statements placed, with a possible range of scores between 0-40. A score of 0 on the BSS-R represents least ‘birth satisfaction’ and 40 the most. Reprinted with permission (Hollins Martin et al., 2020). The Birth Satisfaction Scale-Revised (BSS-R) is available free of charge at: https://www.bss-r.co.uk. The BSS-R is recommended as the key global clinical measure of birth satisfaction by the ICHOM Standard Set for Pregnancy and Childbirth: www.ichom.org/medical-conditions/pregnancy-and-childbirth/

The results of the primary study demonstrated that women who feel more prepared for birth tended to have higher levels of birth satisfaction, those with higher levels of perceived stress tended to have lower levels or birth satisfaction, and those who experienced an instrumental vaginal birth had lower levels of satisfaction than those with other birth types. There were no significant differences in birth satisfaction based upon demographic factors, method of pain control, and whether the baby was born via cesarean surgery or spontaneous vaginal birth (Hinic, 2017). The purpose of this analysis is to gain a richer understanding of women's experiences of birth and their experiences of care by undertaking a qualitative analysis of comments provided by participants on the BSS-R.

Ethical Considerations

The study was reviewed and approved by institutional review boards (IRB) at the principal investigator's university and the hospital where the study was conducted. All data were obtained via participant self-report and no protected health information was included in study data. Participants were identified only by study ID and no records linking study ID number with participant information were maintained. Women were invited to participate in the qualitative component of the study, based upon their involvement in the survey.

Design

The research methodology applied in this study is qualitative content analysis guided by the Thematic Analysis Method (Braun & Clarke, 2006). Comments provided on the BSS-R by study participants constitute the data for the current study.

Sample

Thirty-nine women (36.4% of the overall study sample) provided narrative comments about their birth experiences on the BSS-R and therefore, constitute the sample for the present analysis. The sample included English-speaking women, ages 21–46 years (M = 32.43, standard deviation [SD] = 4.82), who intended to breastfeed and had given birth to a live full term or late term (≥39 weeks and 0/7 days and ≤42 weeks and 0/7 days gestation) (American College of Obstetricians and Gynecologists [ACOG], 2013) singleton infant in the past 4 days. The sample included women who identified racially as White (n = 32, 82%), followed by Black (n = 4, 10%), Asian (n = 2), and other (n = 1, 2%). Fifteen percent of the sample (n = 6) reported Hispanic ethnicity. Most participants (n = 32, 82%) had a bachelor's degree or higher and 97% (n = 38) were married or in a committed relationship. This demographic make-up is consistent with the patient population served by the medical center. The number of qualitative comments received from women who experienced each of the birth types closely mirrored the distribution of the entire sample. Twenty of the women who offered comments had a vaginal birth (51.3%), 10 had a planned cesarean surgery (25.6%), and 9 had an unplanned cesarean surgery (25.6%). The sample was equally comprised of primiparous (n = 19, 48.7%) and multiparous women (n = 20, 51.3%).

Data Analysis

Study data were analyzed to identify themes using codes, descriptions, and patterns, as described by the Thematic Analysis Method (Braun & Clarke, 2006). The Thematic Analysis Method is comprised of six key steps: familiarizing with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report (Braun & Clarke, 2006). Thematic analysis can serve as an essentialist or realist method and can facilitate the reporting of experiences, meanings, and reality of participants, making it an appropriate methodology for present study.

Following the steps of the Thematic Analysis Method, BSS-Rs were reviewed by the principal investigator and all comments were transcribed verbatim into a separate document, listed, and coded to correspond to questionnaire number where they were found. Similar statements were grouped together to generate potential themes. To review the themes, all individual statements contained within the potential list of themes were reviewed for content and whether a sense of pattern had emerged. At this stage, the research team moved several statements and coherent patterns were identified. Themes should represent a patterned response or meaning within the data set (Braun & Clarke, 2006). The themes were considered in relation to the original research question and were labeled according to the descriptions provided by the study participants. The two themes identified were “Unexpected birth processes: expectations and reality” and “Coping with birth: the role of health-care staff.” Data were saturated and no new themes or patterns were identified. Themes will be discussed in the results section and this research article represents the final step of Thematic Analysis, which is producing the report.

Rigor

Trustworthiness is “at the heart” of qualitative research critique (Beck, 2009, p. 544) and demonstrates the value of a study to its readers. Trustworthiness is comprised of auditability, credibility, dependability, confirmability, transferability, and authenticity (Beck, 1993; Beck, 2009; Guba & Lincoln, 1989, 1994). Guba and Lincoln's (1989) criteria were applied to promote trustworthiness and rigor within this study. The use of an established and widely used method for thematic analysis provides a clear map for analysis of data, promoting auditability of the study. Additionally, any comment can be traced back to the original questionnaire as all comments are associated with a participant's number and response to a specific item on the BSS-R. All data for the study are direct participant quotations from study source documents (the questionnaire), which promotes credibility, confirmability, and authenticity (Guba & Lincoln, 1989).

RESULTS

As stated previously, the two themes that emerged from the analysis were “Unexpected birth processes: expectations and reality” and “Coping with birth: the role of health-care staff.” The theme “Unexpected birth processes: expectations and reality” underscores women's experiences of plans changing during labor and the birth process unfolding in a way they did not expect. While some women expressed fear and uncertainty, these unexpected birth processes did not necessarily result in a negative birth experience. The role of nursing staff and the health-care provider in mitigating these often-difficult experiences emerged in the second theme “Coping with birth: the role of health-care staff.” A discussion of the two themes with supportive data from the study follows.

Theme 1: Unexpected Birth Processes: Expectations and Reality

The most common comments from women were related to change of course during the labor and birth experience or unexpected events. These events had a significant effect on the woman's perceptions of her birth experience, as evidenced by the following statements provided by participants:

Attempted VBAC ending in emergency C-section was upsetting/disappointing.

This was my first time and it ended up in a C-section. It was a long labor that turned into a C-section. It was stressful & mentally exhausting.

Things did no [sic] go like I thought they would. The emergency C-section was scary and upsetting. The C-section was scary. It was not what I expected at all.

I had tissue stuck to my uterus which caused bleeding and needing a blood transfusion. The birth part was fine, it was the after birth part that was distressing.

Interestingly, although there were a fair number of comments made in relation to the distressing and disappointing nature of emergency cesarean surgeries, this was not congruent with the quantitative findings from this study. Mothers who experienced unplanned cesarean surgery did not have significantly lower levels of birth satisfaction than those who had other types of births (Hinic, 2017). Other interventions during birth contributed to feelings of anxiety during labor, as illustrated by these two representative comments:

I had trouble with anesthesia (spinal block). I did not labor. I was anxious due to spinal block making me feel ill.

I feel like the sedative I was given was poorly timed as my labor had progressed faster than anyone was aware. It made me anxious and confused during labor/delivery.

Comments related to unplanned or distressing birth experiences were often accompanied by other comments regarding how health-care professionals shaped the experience by their actions, which represents the second emerging theme.

Theme 2: Coping With Birth: The Role of Health-Care Professionals

Many participants shared information on how health-care professionals, including nursing staff and attending physicians and midwives, shaped their birth experience. Women described health-care professionals' role in creating a calm environment during the labor and birth process, even when things did not go as planned. The following data bits support the role of health-care staff in creating this type of milieu:

The staff was excellent and professional when the after birth complications happened.

I was anxious about the C-section, but the staff was wonderful.

I had an emergency c-section because my baby's cord had a knot. Everyone at the hospital was great, but it was scary.

Overall, it was a good experience. Staff answered all of my questions + kept me informed. They were also very calming for a chaotic experience.

As the last statement also suggests, health-care providers were seen by women as advocates, keeping them informed throughout their birth experience. Further support for this role of staff is evidenced by the following participant statements:

Hospital staff was very helpful with addressing questions and concerns. Each staff member offers a different answer but all helpful information.

Midwives made suggestions on my best behalf

The nurses and doctors were wonderful!

Most distress caused by rapid delivery. Tub, midwife, and doula were wonderful!

While most comments related to staff was very positive, the few negative comments demonstrate the importance of respect for the childbearing woman's preferences and her control over her experience:

They wanted me to use Pitocin even though I DID NOT want it.

They weren't happy about my decision to do non-medicated birth.

One nurse kept pushing me to get an epidural when I wanted to push through

Analysis of this data, extracted directly from comments written by new mothers on the BSS-R, provides valuable insight into what matters to women in evaluating and processing their birth experience. Discussion of these themes in the context of the current literature will provide further context for how this data contributes to the overall body of knowledge related to birth experience and satisfaction.

DISCUSSION

Results of this study are consistent with what has been reported in the literature previously and add to the body of knowledge regarding birth satisfaction. Similar to the comprehensive review of qualitative study that informed the construction of the original BSS (Hollins Martin & Fleming, 2011), stress during labor and quality of care as experienced by the patient were of paramount importance in shaping the birth experience.

Hollins Martin and Robb (2013) found that women were able to shift their plans and expectations for birth experience due to their own or their baby's changing needs and they felt satisfied when they felt in control of the change and received adequate explanations from their midwives. In a recent descriptive qualitative study, Baxter (2020) found that without appropriate support from staff, a woman's pain and any unexpected interventions in labor had a far greater negative emotional impact. Another recent qualitative study which described first time mother's experiences with cesarean surgery revealed similar feelings of fear related to the unknowns of the operating room, surgical procedures, and anesthesia (Puia, 2018) as were observed in this sample.

The theme of “Unexpected birth processes: expectations and reality” aligns closely with the stress experienced during labor described by Hollins Martin et al. (2020). Medical interventions, particularly those that result in some sort of injury to the mother or infant, have been consistently associated with lower degrees of birth satisfaction. In their model of childbirth satisfaction, Preis et al. (2019) findings support that lower levels of birth satisfaction are associated with a more medicalized birth and greater incongruence between what the woman had planned and what actually happened. Additionally, this study highlighted the mediating role of perceived control, which included perceived control over the birth environment and process, in the overall birth experience. Other studies that support decreasing satisfaction with increasing interventions include a recent Swedish study in which Kempe and Vikström-Bolin (2020) found birth satisfaction levels to be higher among women with a shorter duration of labor and those who experienced fewer interventions during birth. In this study, those with operative vaginal birth had the lowest satisfaction scales across types of birth. Similar findings were noted in a recent Italian study (Fumagalli et al., 2020) with greater intervention being associated with lower degree of satisfaction.

The role of health-care professionals in helping or hindering a woman's coping during labor, often despite potentially unexpected or stressful circumstances, has been demonstrated in the literature. The World Health Organization (WHO, 2016) framework for improving quality of care for mothers and newborns identifies two critical components of care: quality of care and the quality of care as experienced by women and their families. Communication and care provided by nurses, midwives, and physicians during labor and birth directly inform these two quality indicators. Baxter (2020) found the primary reason for women to report a negative birth experience was lack of support by health-care professionals. Staff members played a key role in a woman's experience of birth and five subthemes including “trust in staff,” “the need for sensitive communication,” “relationships with staff,” “supported by staff,” and “the need for information” emerged in this study. Like the mothers in the present study, participants in this study emphasized the need for staff to listen to them and involve them in decision-making. This theme has been reported in other studies (McKenzie-McHarg et al., 2015). Another study related to labor support and birth experience in a sample of women in Finland (N = 260) demonstrated significant positive correlations of emotional (p < .001), tangible (p < .001), and informational (p = .006) support during labor with birth experience (Nikula et al., 2015). The role of professionals caring for women during labor and birth has a direct effect on how a woman perceives and processes her birth experience. As much of our study data reveals, women expressed feeling “anxious,” or “scared” and described “chaotic” experiences; however, staff were able to mitigate these feelings through emotional and informational support. Hollins Martin et al. (2020) describe the midwife's role in reducing stress and its associated fight or flight response to promote a positive birth experience.

In addition to care providers during labor and birth, prenatal health-care professionals such as childbirth educators can have a significant role in promoting a positive and satisfying birth experience by contributing to effective preparation for birth. Systematic birth preparation has been shown to result in decreased pain during labor, improved communication with health-care providers, and more active involvement with decision-making before, during, and after birth. Participation in childbirth classes can have a positive effect on psychological health of new mothers (Jakubiec et al., 2014) and decrease the number of false labor admissions (Edmonds & Zabbo, 2017). Additionally, women who feel more prepared for birth tend to have more positive birth experiences (Hinic, 2017; Hollins Martin & Robb, 2013). While traditional group childbirth education classes may be limited currently due to social distancing requirements and general health risks for pregnant women in the midst of the COVID-19 pandemic, the value of virtual perinatal education with a childbirth educator has been demonstrated in emerging studies (Pasadino et al., 2020). Women in this study reported feelings of distress when things did not go as planned. Childbirth education programs that provide evidence-based strategies to promote normal birth and cope with the stresses during labor can serve as a valuable tool in promoting a positive birth experience.

Limitations

Study limitations are an important consideration in application of research findings. The main limitations of this study include recruitment of participants from a single clinical agency as well as the sample demographics, which included primarily White, well-educated, married women. These factors limit the generalizability of findings beyond mothers sharing this demographic profile. Finally, because this study analyzed qualitative data collected from a survey tool, it did not elicit the same degree of rich description that might have been uncovered in individual participant interviews.

Implications for Practice

Promoting Physiologic Birth

Many of the comments focused on unexpected birth processes or negative emotions were associated with the stress of interventions during labor and birth. While cesarean surgery and other interventions during labor can be lifesaving, the WHO (2015) has concluded that cesarean rates of greater than 10% are not associated with lower maternal and newborn mortality. Additionally, there is a growing body of evidence that supports physiologic birth or “one that is powered by the innate human capacity of the woman and fetus” (American College of Nurse-Midwives et al., 2013, p. 15) as a pathway to a higher quality, better value maternity care system (Avery et al., 2018). Interruptions to normal hormonal physiology can make labor more difficult, increase the chance of fetal distress requiring more interventions, interrupt maternal–newborn bonding, and increase the risk of multiple cesarean surgeries and their associated risk for complications (Avery et al., 2019). Support of physiologic birth through educational preparation and evidence-based care practices during labor and birth will likely have a positive effect on birth satisfaction and maternal–newborn health outcomes overall. The NASEM (2020, p. 2) suggests that the “right amount of care at the right time” is key to improving birth outcomes while limiting overuse of unneeded care and the underuse of beneficial care. This is a multidisciplinary endeavor with important contributions from midwives, physicians, nurses, and childbirth educators at all stages of the childbearing process.

Respectful Person-Centered Care

The ability to listen to childbearing women and to acknowledge their perceptions as “normal” is key to the family's experience of care. Disrespect in maternity care has been documented in all sectors, across lines of race, ethnicity, ability, and socioeconomic status and disproportionately affects those from traditionally marginalized groups (NASEM, 2020). Components of respectful care in maternity settings includes listening to pregnant women and responding appropriately, providing risk information in an understandable format, and discussing choices around interventions and care and respecting the choices made by women and families. Specifically, to empower the childbearing woman as a full partner in shared decision-making, providers should specifically elicit a woman's values, preferences, and fears about the birth experience she hopes for (NASEM, 2020).

Childbirth Preparation

The goals of formal childbirth education today are to promote informed decision-making, teach mothers to advocate for themselves, learn about pain management, parenting, and infant feeding, and how to effectively navigate the hospital birth experience (Lothian, 2016). In the 21st century, childbirth preparation often consists of a blend of formal classes, Internet-based resources, family, and friends. The compelling evidence that supports participation in formal evidence-based childbirth preparation programs provides a strong foundation for encouraging all pregnant women and their partners to access this type of education. This is particularly important in contemporary society when women have access to an exponential amount of information online, much of which is not peer-reviewed and may not be based on the best evidence (Weatherspoon et al., 2015). Childbirth education empowers families to become prepared for birth and parenthood and sets them up to serve as equal partners with their care providers in decision-making for themselves and their babies during labor and birth.

Implications for practice and education:

• Engage families in childbirth preparation to promote knowledge, confidence, and autonomy in childbirth

• Educate families on the benefits of spontaneous onset and progression of labor

• Provide a supportive environment for birth including privacy, warmth, and minimal switching of care providers

• Minimize unnecessary interventions during labor and birth

• Support early initiation of breastfeeding

• Avoid separation of mother and newborn

• Promote person-centered care including fully informed shared decision-making

CONCLUSION

The experience of childbirth is unique to each woman and family, but the experience of safe, high-quality, respectful maternity care should be accessible to all. The results of this study provide insight into the experience of childbirth in one sample of women that leads to implications and recommendations for care, consistent with what has been found on a national and global level. Regardless of interventions utilized during the birth process, women and families benefit greatly from health-care professionals who are respectful and take the time to empower them to make their own informed choices. Assisting childbearing families to make their own informed choices with the support of knowledgeable and caring health-care professionals will result in improved experiences of giving birth.

Biography

KATHERINE HINIC is an assistant professor of nursing at Seton Hall University College of Nursing in Nutley, NJ, where she teaches graduate level coursework in maternal newborn nursing, research, and health policy. Her research focuses on maternal newborn health promotion and care quality.

DISCLOSURE

The author has no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

FUNDING

The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.