What women emphasise as important aspects of care in childbirth: An online survey study of 8,401 women who have given birth in Norway
Carina Vedeler1
Anne Britt Vika Nilsen2
Ellen Blix1
Soo Downe3
Tine S. Eri1
1Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
2Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
3Research in Childbirth and Health (ReaCH) group/THRIVE Centre, University of Central Lancashire, Preston, UK
Corresponding author:
Carina Vedeler
Email: calian@oslomet.no
Postboks 4, St. Olavs Plass
0130 Oslo, Norway
Phone: +47 40862987
Short running title: Important aspects of care during childbirth
Abstract
Objective
To explore and describe what women who have given birth in Norway emphasise as important aspects of care during childbirth.
Design
The study is based on data from the Babies Born Better survey, version 2, a mixed-method online survey.
Setting
The maternity care system in Norway.
Study population
Women who gave birth in Norway between 2013 and 2018.
Method
Descriptive statistics were used to describe sample characteristics and to compare data from the B3 survey with national data from the MBRN, using SPSS® software (version 20). The open-ended questions were analysed with an inductive thematic analysis, using NVivo 12® software.
Main outcome measures
Themes developed from two open-ended questions.
Results
The final sample included 8,401 women. There were no important differences between the sample population and the national population with respect to maternal age, marital status, parity, mode of birth and place of birth, except for the proportion of planned homebirths. Four themes and one overarching theme were identified; Compassionate and Respectful Care, A Family Focus, Continuity and Consistency, and Sense of Security, and the overarching theme Coherence in Childbearing.
Conclusions
Socio-cultural and psychological aspects of care are significant for women in childbirth, alongside physical and clinical factors. Caring for the woman implies caring for her partner and having a baby is about ‘becoming a family or expanding the family’. Childbirth is a continuous experience in women’s lives and continuity and consistency are important for women to maintain and promote a coherent experience.

Key words

Midwifery care; Childbirth experience; Intrapartum care; Salutogenesis; Coherence in Childbearing; Thematic analysis
Tweetable abstract
A national survey of more than 8,000 women in Norway showed that childbirth is a life event, not just a clinical procedure, and that continuity and consistency of care are important to maintain and promote a coherent experience.
Introduction
Childbirth is an important existential experience in a woman’s life. Childbearing women value a positive birth experience, and WHO recognises a ‘positive childbirth experience’ as a significant end point for all women who have given birth.1-3
Paying attention to service users’ views and experiences is a crucial part of improving and developing maternity care.1,4,5It is important to develop and provide maternity services that women want and need.2 The literature on women’s negative and traumatic birth experiences is extensive.6-10 However, there is much less evidence about the nature of positive childbirth experiences and the impact on good health for women and families.
Salutogenic theory focuses on what promotes good health. The theory was first introduced by Antonovsky11 who suggested that health is movement on a continuum of ease and dis-ease, unlike the dichotomy of healthy or sick. There is good evidence that salutogenesis is a useful theory for maternity care research.12-14
To the best of our knowledge, this is the first study with such a large sample of childbearing women, asking for women’s views on what worked well in their maternity care experience. The main objective of this study is to explore and describe what women who have given birth in Norway emphasise as important aspects of care during childbirth, with a focus on salutogenic theory.
Methods
Design
This study is based on data from the Babies Born Better survey, version 2, a mixed-method online survey.
Setting
The context of the current paper is the Norwegian maternity care system, which is part of the public health care system. It is tax funded and provided free of charge at the point of use. Midwives and doctors have a fixed salary, and thus have no economic interest in how a labour proceeds. Virtually all women in Norway receive maternity care from the public health care system. Intrapartum care is organised at three levels; 1) specialised obstetric units, 2) smaller obstetric units and 3) alongside and freestanding midwifery units. Midwives attend all births. Apart from a few independent midwives offering antenatal care, homebirths and post-partum care, there are no private birth institutions. There were 45 birth units in Norway in the study period, and approximately 58,000 births per year. The population is widely scattered and is characterised by both centralisation and decentralisation. More than 45% give birth in the five largest hospitals, however there are 19 units with less than 500 births per year, the caesarean section rate in 2019 was 16%, epidural anaesthesia 36%, and vacuum or forceps 10%.15
Study population
Women who gave birth in Norway during the period 2013 to 2018 were eligible to participate.
Data collection
The survey was open from March to August 2018. It was launched through social media, mainly through Facebook where the link was widely disseminated to relevant Facebook groups. We also contacted specifically targeted websites and asked them to post the survey on their web forums.
The questionnaire
The survey was an open online survey (SurveyMonkey®), comprising 22 questions (Appendix S1) with sub-questions divided into four sections, including both closed and open-ended response options. The first three sections comprised questions related to demographics and maternal characteristics; age, marital status, migration, self-rated socio-economic status, education, employment status, parity, gestational age, mode of birth and place of birth. The fourth section included two open-ended questions; the first designed to elicit women’s views of what worked well during their childbirth experience, and what they think would have improved their experience of care, the second asked for an honest description of the place where they had their baby, and reasons why they would, or would not, recommend it as a birthplace to a close friend or family member.
The Medical Birth Registry of Norway (MBRN)
To assess the representativeness of the study sample, a Norwegian population-based sample with information about maternal age, marital status, parity, place of birth and mode of birth, from the Norwegian birth cohort of all women who gave birth in 2017 was retrieved from MBRN.15
Analysis
Descriptive statistics were used to describe sample characteristics and to compare data from the B3survey with the national population-based data sample from the MBRN, using SPSS® software (version 26).
We performed thematic analysis16 to analyse the two open-ended questions (Q17, Q18). An inductive approach was chosen. Thematic analysis is a method for identifying, analysing and reporting patterns or themes within a data set. The analytical process was data driven, dynamic and continuously discussed in the research group. The stepwise process is illustrated in Figure 1. See Appendix S2 for a more in-depth description of the analytical process. Quality assessment was done using the CHERRIES checklist17 (Appendix S3).
Ethics
Ethical approval was granted by the Ethics Committee of the University of Central Lancashire, UK (Ethics Committee BuSH 222). The study was approved by the Norwegian Data Inspectorate (ref: 60547/3/HJTIRH), no further ethical clearance was necessary (ref: 2017/1582).
Results
Altogether, 11,135 women who had given birth in Norway responded to the survey. The final sample included 8,401 women (Figure 2).

Demographics of the respondents

Table 1 shows the main characteristics of the included respondents. Whenever national data were available in the MBRN, our sample was compared to the population-based sample in 2017 as a census group. Of the included women, 92.3% were born in Norway. The mean age was 29.9 years (SD 5.0), 45% were nulliparous and 55% multiparous. All 45 birth units in Norway were represented in the sample, the response rates by unit were similar to the rate of births in those units for the population (Figure 3). There were no important differences between our sample and the population-based sample regarding age, marital status, parity, mode of birth, place of birth, except for the number of planned homebirths (1.6% in the study, 0.2% in the population). Missing data varied from 0.04-0.7% across the variables, except for education level which was 2.6%.

Findings from the open-ended questions

The analysis of the open-ended questions resulted in four themes; Compassionate and Respectful Care; Sense of Continuity and Consistency; A Family Focus; Sense of Security, and one overarching theme; Coherence in Childbearing. See Appendix S4 for more quotes.

Compassionate and Respectful Care

To be compassionate implied that the staff were genuinely engaged and concerned about the woman’s well-being, through empathy, kindness, attentiveness, love, support, understanding and compassion during labour and birth. If the staff were insensitive or lacked empathy, childbirth was experienced as very difficult and something they would have wanted to change. It was clear that childbirth was perceived as a vulnerable situation that required a sensitive approach. The data implied that simple politeness from the staff was insufficient: the birthing woman needed to feel the care as genuinely intended to be perceived as caring.
‘When we changed midwife, we got one that touched my arm looked me in the eyes and said; this is going well. [she said] Do this and that. [she was] Very clear’
Compassionate and respectful care was also connected to the midwife’s watchful attendance, perceived as the actual time present and an emotional availability that led to a feeling that the midwife was there for her and saw her. The midwife’s emotional presence was perceived as awareness and sensitivity to the woman’s signals and needs.
‘The first midwife I had was so present and accommodating. Almost didn’t have to say anything because she understood what I needed’
To be respected, empowered, seen and listened to as a unique individual led to a sense of partnership when things were to be decided. Having real influence and co-determination in terms of herself and the child was important. If the midwives or doctors were sensitive and acknowledged her wishes, it could lead to a sense of being special and unique and experiencing individual care. If this central aspect was missing, the respondents reported a sense of vulnerability, which was problematic and difficult;
‘Midwives don’t have enough time, they don’t see you as a separate individual, midwives don’t have empathy. A feeling that the hospital had a ”yes but we see this so often” attitude’

Sense of Continuity and Consistency

Continuity refers to the woman’s perception of pregnancy, labour and birth and post-partum as a coherent whole that are not distinguished as different phases. Being allowed to enter the hospital when she felt the need to, in the early stages of labour, was essential;
‘The person I spoke to on the phone before I came in seemed brusque and incomprehensible. Asked me to wait to come in because she thought I was not in enough pain. I had to ”argue” to get an examination. When I came in, I had 7-8 cm dilatation and frequent contractions’
Another facet of continuity was the midwives’ availability throughout the process; the importance of not being left to yourself; and that the midwife had time for the parents and the baby after birth.
Initiation of breastfeeding was also crucial for the sense of continuity, including good breastfeeding support and care throughout the postnatal period.
‘Better help with breastfeeding. I felt that the staff was short of time and had completely different opinions about this. This led to a chaotic and stressful situation’
Continuation and consistency of information was also a part of this concept. It seemed crucial that the staff had read the woman’s birth plan and medical notes, and that previous pregnancies or births were taken into consideration. This does not merely mean that the woman saw the same person, but that all the staff cooperated on sharing and addressing prior information about her, in a way that optimised her sense of seamless care. The sense of continuity was also connected to receiving the information and explanations needed throughout the birth process and to be offered a post-partum conversation.

A Family Focus

A family focus in care involved not only the partner’s inclusion in the birth process, but also that giving birth to a child is primarily about ’becoming a family’ or ’expanding the family’.
‘The father and I as a unit that did this together’
It was therefore crucial for the women that their partners were involved and felt included and that his/her experiences, feelings and needs were acknowledged.
‘That staff listen to both the mother and father of the child. That staff include the father more. The expensive accommodation for partners meant we could not afford to be there together, very difficult and tiring as a new mother all alone without sleep’
The partner’s presence and care were crucial to the women, but the midwife’s care for the partner was also of great importance. A lack of care for the partner raised difficult emotions for the woman. This was so important that some women noted that it was very positive that their partner was well cared for by staff. Involving and including the partner seemed to be a twofold matter. Firstly, care for their physical condition, including the opportunity for rest, to fetch food and be present throughout the stay. Secondly, the emotional aspects which were about the partner feeling included, that they were treated as a family, and that they could spend time together with the new-born baby.
‘Better care of the father both emotionally and physically, he should automatically be able to sleep the first night at the hospital, especially if the baby is born late at night’

Sense of Security

Feeling secure was emphasised as a fundamental part of care by many respondents. While the women linguistically used the same terms, they referred to different meanings regarding what made them feel safe. Feeling secure seemed to encompass both medical, emotional and relational safety. For some women, the aspect of emotional and relational safety seemed most important;
‘Then you’ll have a sense of peace in a safe and familiar environment, without unnecessary stress and interventions, with a midwife who knows you and your wishes’
For others, the notion of medical safety was most important;
‘There’s good expertise among employees, and all the facilities you may need in the event of any complications’
The sense of security was also linked to confidence in the staff’s competence and a perception that the staff was fundamentally trustworthy and acting in the women’s and their babies’ best interest. This both referred to medical competence as a competent hospital team of expert midwives and doctors, and trust in their experience and knowledge. It seemed that trusting the staff’s competence could lead to a sense of being able to lean on them and ”let go” and not worry about whether they knew what they were doing. Doubting whether the staff could offer this sense of security was associated with uncertainty about how safe their birth was, and in their capacity to negotiate it without harm.
‘Didn’t feel the midwife knew what to do when my pain was at its worst, again, want a more secure and experienced midwife’

Overarching theme: Coherence in childbearing

Coherence in childbearing encompasses all four themes. It refers to the woman’s experience of childbearing as a whole and that it is not perceived as a separate event disconnected from both the antenatal and postnatal period or women’s lives in general. It implies an understanding of the woman as a unique person with her own history, cultural background, resources, perceptions and personality. Everything she experiences will be related to this and thus, also, to how she experiences care. The following quotes illustrate what ‘good’ or ‘poor’ care felt like;

Good Care