local (vernacular) language of the mother, audio-taped, transcribed and translated ...... âI was experiencing severe pain and an urge to bear down, but they were ...
A MODEL FOR WOMAN-CENTERED CHILDBIRTH by
MARIA SONTO MAPUTLE THESIS
Submitted in Fulfillment of the Requirements for the Degree
DOCTOR CURATIONIS
in
MATERNAL AND CHILD NURSING SCIENCE
in the
FACULTY OF EDUCATION AND NURSING
at the
UNIVERSITY OF JOHANNESBURG
Promoter: Professor AGW Nolte
OCTOBER 2004
ii
DECLARATION “I declare that this thesis, A Model for Woman-Centered Childbirth which I submit for the degree of Doctor Curationis in Maternal and Child Nursing Science at the University of Johannesburg, is my own work and that all sources and references are acknowledged.”
__________________
SIGNED
_______________
DATE
iii
DEDICATION
This study is dedicated to my beloved parents, Paulos Mngenelwa and Martha Girly Mkhwebane; and my mother-in-law, Mathildah Pebetse Maputle.
OH, give thanks to the LORD! For He is good. Call upon His name; make known His deeds among the peoples (Psalm, 105:1).
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ACKNOWLEDGEMENTS I wish to thank God the Almighty for blessing me with good health, strength, wisdom and courage to carry out this study. In addition, I want to express my sincere gratitude to the following people: Professor Anna Nolte, my promoter, you facilitated my research study through your guidance, motivation and inspiration. My family, that is, my husband Phaswane, my children, Mduduzi, Duduzile and Palesa, for your patience, support, encouragement and understanding when I couldn’t be with you during my study. My colleagues at work for their inspiration and assistance. To Mrs MN Jali, a special thanks for being there for me during the discouraging moments and Mrs EE Radithlalo, for taking over the student teaching during my absence. The mothers and the attending midwives of Mankweng Hospital for participating in and providing valuable information pertaining to the study. The Directorate, Department of Health Research Ethics Committee and the Mankweng Hospital Management for granting me permission to carry out this study. Dr DC Hiss, School of Health Sciences, University of the North, for painstakingly editing the manuscript.
v
ABSTRACT The overall objective of this study was to describe the model and criteria for woman-centered care that will serve as a theoretical framework for implementing the Batho-Pele Principles in order to facilitate mutual participation between mothers and attending midwives during childbirth at one hospital of the Capricorn district in the Limpopo Province.
The phases followed in this study were as follows:
Phase 1: Concept Identification The concept identification was achieved through the use of a qualitative research approach which was exploratory, descriptive, contextual and inductive. A sample of 24 mothers and 12 attending midwives participated in the study. Different data collection methods were utilized. Data obtained from unstructured in-depth interviews were analyzed according to the protocol by Tesch (1990; cited in Cresswell, 1994:155). Data analysis from participant observation using semistructured observation and VAS were performed quantitatively by using frequency distribution. The results of interviews indicated experiences that foster/promote dependency in midwifery care. Woman-centered care was identified as a core category and as a central approach that would enhance mutual participation during childbirth. To ensure valid results, a model of trustworthiness as proposed by Lincoln and Guba (1985: 301-318) was utilized.
Phase 2: Concept Analysis Following the concept identification, the concept analysis of a core category ‘woman-centered care’ was conducted using the framework as described by Walker and Avant (1995).
vi
Phase 3: Development of the Model and Criteria This phase dealt with the description of the structure and process of the model. Strategies were proposed, described and recommended to implement the model where there is interaction of a mother (patient) and a midwife (nurse). Evaluation of the model was done by having dialogue with experts and by utilizing Chinn and Kramer’s (1995:134-135) guidelines for evaluating theory. The criteria for womancentered care were formulated. A unique contribution of this study is the concept analysis of woman-centered care, the development and description of the womancentered childbirth model and the formulation of criteria for woman-centered care
vii
OPSOMMING Die algehele doel van hierdie studie was om ʼn model en kriteria te beskryf vir vrougefokusde sorg wat kan dien as ʼn teoretiese raamwerk vir die implementering van die Batho-Pele beginsels vir die fasilitering van wedersydse deelname tussen moeders en bywonende voedvroue gedurende geboorte by een hospitaal in die Capricorn distrik, Limpopo Provinsie. Die volgende stappe is gevolg in hierdie studie: Stap 1: Konsep Identifikasie ʼn Verkennende, beskrywende, kontekstuele en kwalitatiewe navorsingsontwerp is gebruik vir konsep identifikasie. ʼn Groep van 24 moeders en 12 bywonende voedvroue het deelgeneem aan die studie. Verskillende metodes is gebruik om data in te samel. Data verkry van die ongestruktureerde in-diepte onderhoude is geanaliseer volgens die protokol deur Tesch (1990; verwys in Creswell, 1994:155). Dataverwerking van observasies verkry van semi-gestruktureerde vraelyste en VAS is kwantitatief geanaliseer deur frekwensie verdeling. Die resultate het tendense aangetoon wat afhanlikheid van voedvrousorg bevorder. ‘Vrou-gefokusde sorg’ is geïdentifiseer as ʼn kern kategorie en ʼn sentrale benadering wat wedersydse deelname tydens geboorte sal verbeter. Die model van Lincoln en Guba (1985:301-318) is gebruik om betroubaarheid in hierdie kwalitatiewe ondersoek te verseker. Stap 2: Konsep Analise Die konsep analise van die kern kategorie vrou-gefokusde sorg was uitgevoer na konsep identifikasie. Die raamwerk beskryf deur Walker en Avant (1995) is gebruik vir konsep analise.
viii
Stap 3: Ontwikkeling van die Model en Kriteria Beskrywing van die struktuur en proses van die model is in hierdie stap voltooi. Riglyne en aanbevelings is geformuleer om die model te implementer tydens interaksie van ʼn moeder (pasiënt) en voedvrou (verpleegster). Riglyne van Chinn en Kramer (1995:134-135) asook onderhoude met deskundiges is gebruik vir evaluering van die model.Die criteria vir vrou gefokusde sorg is geformuleer. ʼn Unieke bydrae van hierdie studie is die konsepanalise van vrou-gefokusde sorg, die ontwikkeling, beskrywing en formulering van kriteria vir die vrou-gefokusde model.
ix
TABLE OF CONTENTS TITLE PAGE DECLARATION DEDICATION ACKNOWLEDGEMENTS ABSTRACT OPSOMMING TABLE OF CONTENTS LIST OF TABLES LIST OF FIGURES CHAPTER 1 1.1 1.2 1.3 1.4 1.5 1.6 1.6.1 1.6.1.1 1.6.1.2 1.6.1.2.1 1.6.1.2.2 1.6.1.2.3 1.6.1.2.4 1.6.2 1.7 1.7.1 1.7.2 1.7.3 1.7.4 1.8 1.9 1.10 1.11 1.12 1.13
ORIENTATION INTRODUCTION RATIONALE AND BACKGROUND OF THE PROBLEM PROBLEM STATEMENT RESEARCH QUESTIONS PURPOSE AND OBJECTIVES PARADIGMATIC PERSPECTIVE Meta-Theoretical Assumption Theories and Models Definitions of Concepts Used in this Research Study Experiences Childbirth Biomedical Model Woman-Centred Care Methodological Assumptions RESEARCH METHODOLOGY Research Design and Method Data Collection Population and Sampling Data Analysis CONCEPT ANALYSIS TRUSTWORTHINESS LITERATURE CONTROL ETHICAL CONSIDERATIONS DIVISION OF CHAPTERS SUMMARY
i ii iii iv v vii ix xvi xvi
1 1 1 5 5 5 6 6 6 7 7 7 7 7 8 8 8 9 11 11 12 12 12 12 13 13
x CHAPTER 2 2.1 2.2 2.2.1 2.2.2 2.2.3 2.2.4 2.2.5 2.2.6 2.2.6.1 2.2.6.2 2.2.6.3 2.3 2.4 2.5 2.5.1 2.5.1.1 2.5.1.2 2.5.1.3 2.5.1.4 2.5.1.5 2.5.2 2.6 2.6.1 2.6.2 2.7 2.7.1 2.7.2 2.8 2.9 2.10 2.10.1 2.10.2 2.10.3 2.10.4 2.11 2.12 2.12.1 2.12.2 2.12.3 2.13
RESEARCH METHODOLOGY
14
INTRODUCTION RESEARCH DESIGN AND METHOD OF DATA COLLECTION Qualitative Research Design Explorative Research Design Descriptive Research Design Contextual (Idiographic) Research Method Inductive Research Method Reasoning Strategies for Analysis and Synthesis Analysis Synthesis Deduction PREPARATION FOR DATA COLLECTION THE PILOT STUDY DATA COLLECTION Data Collection for Mothers Unstructured In-Depth Interview Participant Observation Visual Scale analog (VAS) Unstructured Conversation Field Notes Data Collection for Attending Midwives POPULATION AND SAMPLING Target Population for Mothers Target Population for Attending Midwives DATA ANALYSIS Quantitative Data Analysis Qualitative Data Analysis CONCEPT ANALYSIS DEVELOPMENT OF CHILDBIRTH MODEL TRUSTWORTHINESS Credibility Dependability Transferability Confirmability LITERATURE CONTROL ETHICAL CONSIDERATIONS The Quality of the Research Confidentiality and Anonymity Right to Self-Determination SUMMARY
14 15 15 15 16 16 17 17 17 18 18 18 18 19 20 20 21 22 23 23 23 24 24 25 26 26 27 29 29 29 30 30 31 31 32 32 32 33 33 33
xi CHAPTER 3
DISCUSSION OF RESEARH FINDINGS:
34
THE EXPERIENCES OF CHILDBIRTH BY MOTHERS 3.1 3.2 3.2.1 3.2.1.1 3.2.1.2 3.2.1.3 3.2.1.4 3.2.1.5 3.2.2 3.2.2.1 3.2.2.2 3.2.2.3 3.2.2.4 3.2.3 3.2.3.1 3.2.3.2 3.2.3.3 3.2.3.4 3.2.4 3.2.4.1 3.2.4.2 3.2.4.3 3.2.4.4 3.2.5 3.2.5.1 3.2.5.2 3.3 3.3.1 3.3.2 3.3.3 3.3.4 3.3.5 3.4
INTRODUCTION DISCUSSION OF RESULTS: MOTHERS CATEGORY 1: MUTUAL PARTICIPATION AND RESPONSIBILITY SHARING Theme A: Participation/Lack of Participation Theme B: Responsibility/Lack of Responsibility in Own Care Theme C: Dependency Theme D: Decision Making/Lack of Decision Making Theme E: Facilitation/Promotion of Participation and Involvement CATEGORY 2: INFORMATION SHARING AND EMPOWERING Theme A: Limited Information about Childbirth Issues and Available Choices Theme B: Autonomy/Lack of Autonomy Theme C: Informed Choices/Lack of Making Informed Choices Theme D: Empowering/Powerlessness CATEGORY 3: OPEN COMMUNICATION AND LISTENING Theme A: Verbal/Hindered Verbal Communication Theme B: Trust/Lack of Trusting Relationship Theme C: Physical/Lack of Physical Comforting Measures and Emotional Support Theme D: Authoritative Approach (Limited Human Rights) CATEGORY 4: ACCOMODATIVE/NON-ACCOMODATIVE ACTIONS Theme A: Guide, Support and Respect of Choices Theme B: Presence of Companion Theme C: Conflicting Expectations Theme D: Unrealistic Choices CATEGORY 5: HUMAN AND MATERIAL INFRA-STRUCTURE Theme A: Shortage of Staff Theme B: Labour Ward Infrastructure RESULTS OF THE OBSERVATION ON ACTIVITIES AND INTERACTION DURING CHILDBIRTH Communication Between Mothers and Attending Midwives During Childbirth Informational Support During Childbirth Emotional Support During Childbirth Physical Comforting Measures When Mothers Respond to Pain Supportive Care Activities During Childbirth SUMMARY
34 36 36 38 39 40 41 41 42 42 43 44 45 46 46 47 47 48 49 49 49 51 52 52 52 53 53 54 55 57 59 60 61
xii CHAPTER 4
4.1 4.2 4.2.1 4.2.1.1 4.2.1.2 4.2.1.3 4.2.1.4 4.2.1.5 4.2.2 4.2.2.1 4.2.2.2 4.2.2.3 4.2.2.4 4.2.3 4.2.3.1 4.2.3.2 4.2.3.3 4.2.3.4 4.2.4 4.2.4.1 4.2.4.2 4.2.4.3 4.2.4.4 4.2.5 4.2.5.1 4.2.5.2 4.3
CHAPTER 5
5.1 5.2 5.2.1
DISCUSSION OF RESEACRH FINDINGS: THE EXPERIENCES OF ATTENDING MIDWIVES ON MANAGING MOTHERS DURING CHILDBIRTH INTRODUCTION DISCUSSION OF FINDINGS: ATTENDING MIDWIVES CATEGORY 1: MUTUAL PARTICIPATION AND RESPONSIBILITY SHARING Theme A: Participation/Lack of Participation Theme B: Responsibility/Lack of Responsibility in Own Care Theme C: Dependency Theme D: Decision Making/Lack of Decision Making Theme E: Facilitation/Promotion of Participation and Involvement CATEGORY 2: INFORMATION SHARING AND EMPOWERING Theme A: Limited Information About Childbirth Issues and Available Choices Theme B: Autonomy/Lack of Autonomy Theme C: Informed Choices/Lack of Making Informed Choices Theme D; Empowering/Powerlessness CATEGORY 3: OPEN COMMUNICATION AND LISTENING Theme A: Verbal/Hindered Verbal Communication Theme B: Trust/Lack of Trusting Relationship Theme C: Physical/Lack of Physical Comforting Measures and Emotional Support Theme D: Authoritative Approach (Limited Human Rights) CATEGORY 4: ACCOMODATIVE/NON-ACCOMODATIVE ACTIONS Theme A: Guide, Support and Respect Of Choices Theme B: Presence of Companion Theme C: Conflicting of Expectations Theme D: Unrealistic Choices CATEGORY 5: MAXIMIZE HUMAN AND MATERIAL INFRASTRUCTURE Theme A: Shortage of Staff Theme B: Labour Ward Infrastructure SUMMARY
COMBINATION OF THE RESULTS OF MOTHERS AND ATTENDING MIDWIVES AND LITERATURE CONTROL INTRODUCTION COMBINATION AND DISCUSSION OF SIMILARITIES AND DIFFERENCES Section One: Presentation of Data
62 62 63 64 64 66 67 67 68 69 69 70 71 72 72 72 73 73 74 75 75 76 77 77 78 78 78 79
80 80 80 81
xiii 5.2.1.1 5.2.1.2 5.2.1.3 5.2.1.4 5.2.1.5 5.2.1.6 5.2.2 5.2.2.1 5.2.2.2 5.3 5.3.1 5.3.2 5.3.3 5.3.4 5.3.5 5.3.5.1 5.3.5.2 5.3.5.3 5.3.6 5.4
CHAPTER 6 6.1 6.2 6.2.1 6.2.2 6.2.3 6.2.3.1 6.2.4 6.2.5 6.2.6 6.2.6.1 6.2.6.2 6.2.7 6.3 6.3.1 6.3.2 6.3.3 6.3.4 6.3.5
Mutual Participation, Responsibility Sharing, Dependency and Decision-Making Information Sharing, Empowering and Autonomy Communication and Listening, Trust Relationship, Physical Comfort and Emotional Support Accommodative Midwifery Actions, Presence of Companion Shortage of Staff and Ward Structure Facilitation/Promotion of Participation CLUSTERS OF CATEGORIES ACCORDING TO THEIR RELATIONS Midwife-Centered Care Woman-Centered Care Section Two: The Literature Control Limited Mutual Participation and Responsibility Sharing Limited Information Sharing and Empowering Actions Ineffective Communication Limited Physical Comforting Measures Non-Accommodative Midwifery Actions Respect Limited/Minimal Presence of A Companion Expectations Limited Human and Material Infrastructure SUMMARY
86 87 89 89 94 96 98 99 99 99 100 100 101
A WOMAN-CENTERED CARE: CONCEPT ANALYSIS
102
INTRODUCTION CONCEPT ANALYSIS Select a Concept Aims of Analysis Identifying Uses, Characteristics or Connotations of the Concept Connotations of Woman-Centered Care that emerged from Literature
102 102 103 103 103
Determine Defining Attributes Develop the Model Cases Identify Antecedents and Consequences Antecedents Consequences Define Empirical Referents COMPONENTS OF THE THEORY Goals Concepts Definitions Relationships Structure
81 82 83 83 84 84 85
105 105 107 109 109 110 110 111 111 112 112 112 112
xiv 6.3.5.1 6.3.5.2 6.3.6 6.4 6.5 6.6 CHAPTER 7
7.1 7.2 7.3 7.3.1 7.3.1.1 7.3.1.2 7.3.2 7.3.3 7.3.4 7.3.4.1 7.3.4.2 7.4 7.5 7.6 7.6.1 7.6.2 7.6.3 7.6.4 7.6.5
7.7
Conceptual Model Process of the Model Assumptions EVALUATION OF THE MODEL FORMULATION OF CRITERIA FOR WOMAN-CENTERED CARE SUMMARY CONCLUSIONS, VALIDATION, LIMITATIONS RECOMMENDATIONS OF THE STUDY
112 116 126 126 127 133
AND
INTRODUCTION CONCLUSIONS OF STUDY VALIDATION OF THE DEVELOPED MODEL AND STRATEGIES Methodology for Validation Process Sampling Preparation for Data Collection Data Collection for the Midwifery Experts Planning for Application of the Theory/Model Data Collection for the Policy Makers, Unit Managers and Midwifery Care Providers Developed Strategies Formulated Criteria THE GOALS AND CONCLUSIONS OF THE APPLICATION OF THE MODEL AND INTERVENTION STRATEGIES LIMITATIONS OF THE STUDY RECOMMENDATIONS OF THE STUDY Recommendations for Implementation In Obstetrical Unit Recommendations for Implementation In General Nursing Units Recommendations for Implementation In Nursing Research Units Recommendations for Implementation In Neonatal/Maternity Units Recommendations for Implementation by the Department of Health, Maternal, Child and Woman’s Health Directorate in Limpopo Province SUMMARY
134 134 134 139 139 139 140 141 143 144 144 148 151 151 152 152 153 153 154 154 155 156
BIBLIOGRAPHY ADDENDUM 1 (A)
Request for Permission to Conduct Research (A)
166
ADDENDUM 1 (B)
Request for Permission to Conduct Research (B)
169
ADDENDUM 2 (A)
Informed Consent Form for Mothers
170
xv ADDENDUM 2 (B)
Informed Consent Form for Attending Midwives
172
ADDENDUM 3
Biographical Data and Transcripts for Mothers
174
ADDENDUM 4
Biographical Data and Transcripts for Attending Midwives
181
ADDENDUM 5
Semi-Structured Participant Observation Guide (Checklist)
187
ADDENDUM 6
Visual Analog Scale (VAS) = 100mm
189
ADDENDUM 7
A Guide to Validate Whether the Model Can Be Applied to Practice
190
ADDENDUM 8
Guide To Validate Whether The Strategies Can Be Implemented In The Clinical Practice
193
ADDENDUM 9
Limpopo Province Department of Health Permission Letter
196
ADDENDUM 10
Approval of Field of Study
197
xvi
LIST OF TABLES Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7 Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 5.1 Table 6.1 Table 6.2 Table 6.3 Table 6.1
Profile Of Mothers Recruited To The Study Categories and Themes Category 1: Mutual Participation and Responsibility Sharing Category 2: Information Sharing and Empowering Category 3: Open Communication and Listening Category 4: Accommodative/Non-Accommodative Midwifery Actions Category 5: Maximize Human and Material Infrastructure Profile of the Attending Midwives Recruited to the Study Categories and Themes Category 1: Mutual Participation and Responsibility Sharing Category 2: Information Sharing and Empowering Category 3: Open Communication and Listening Category 4: Accommodative/Non-Accommodative Midwifery Actions Category 5: Maximize Human and Material Infrastructure Experiences that were Classified as Practices that Foster/Promote Dependency in Midwifery Care Comparison of Critical Attributes and Characteristics of womanCentered Care Conceptual Model The Batho-Pele Principles Criteria For Woman-Centered Care
36 38 36 42 46 49 52 63 65 64 69 72 75 78 90 109 115 116 129
LIST OF FIGURES Figure 3.1 Figure 3.2 Figure 3.3 Figure 3.4 Figure 3.5 Figure 5.1 Figure 5.2 Figure 6.1 Figure 6.2 Figure 6.3
Interaction/Communication Between Mothers and Attending Midwives Informational Support Emotional Support Activities During Childbirth Pain Scores by Using Visual Analog Scale (VAS) Supportive Care Activities During Childbirth Midwife-Centered Care Woman-Centered Care Theoretical Framework Of Defining Attributes Of Woman Centered Care Synthesis Of Relational Statements Conceptual Model Of Woman-Centered Care
55 57 59 60 61 86 87 107 114 118
1
CHAPTER 1 ORIENTATION
1.1
INTRODUCTION
The experiences of mothers during childbirth deserve attention if appropriate and woman-centered care is to be provided to women in the Limpopo Province, in particular, and in South Africa in general. It is only when women’s voices are heard in the aspects of health care delivery that better and appropriate health services for women in childbirth will be provided.
1.2 RATIONALE AND BACKGROUND OF THE STUDY The Limpopo Province consists of six districts, namely Capricorn, Mopani, Bohlabela, Vhembe, Sekhukhune and Waterberg. Each is further divided into subdistricts and municipalities. Ninety percent (90%) of the province is rural, with poor road and transport facilities and inadequate water and sanitation provisions. As indicated in the Department of Health Reports (2001:54; 2002:52), the total population in the province is 5,514 million of which 54% are females. Of the total female population, 45% are in the childbearing age group. The health service structure consists of one (1) tertiary institution, six (6) districts hospitals (level 2) and thirty six (36) community hospitals (level 1). Amongst the specialties provided at the tertiary institution are obstetrics and gynecological care. The tertiary hospital is therefore a referral hospital for levels 1 and 2 hospitals within the province. The nursing health professionals in the province in 2001 were 5043 professional nurses, including registered midwives.
2
In the Limpopo Province more mothers currently give birth in the hospitals than at home. According to the Department of Health Report (2002:52), the province has a total of 43 hospitals, of which 40 have functioning maternity units for deliveries. An estimated 64% of births occur in the hospitals. When mothers enter the hospital to give birth they are usually unfamiliar with both the surroundings and the structure and not well acquainted with the rules that govern behaviour in the obstetric unit setting. The situation in hospitals that provide childbirth care is such that prescribed routines are adhered to frequently as laid down in the policies and procedures strategically placed in the ward. Midwives generally regard it as their responsibility to ensure that the rules are adhered to. Pearson, Vaughan and Fitzgerald (1998: 34) indicated that the end results of such an approach are standardized routines for mother care during childbirth. It was further pointed out that mothers are often expected to comply with a predictable pattern and follow the routine laid down by the regulations. Such standardized routines do have some merit, but when followed without skilled assessment may pose the risk of depersonalizing the mothers and discouraging any participation and involvement during midwifery care. Childbirth, from the perspective of the biomedical model, focuses on the physiological changes that take place during childbirth. Midwives possess the scientific knowledge with regard to these changes. The model therefore tends to focus more on the management of labour, the detection of complications or normal childbirth. This leads to the devaluing acts related to how mothers are experiencing their own childbirth such as listening, comforting or offering choices. Thus this model is not geared to meet the needs of the mothers. Pearson et al. (1998:36) viewed the biomedical model as a reductionist and dualistic approach because it reduces the human body to a set of related parts and further separates the mind from the body. The biomedical model and its dominant effect on health care have led to it being used in the interest of the midwives.
3
For example: • The model concentrates information and decision making in the hands of doctors and midwives and to a lesser extent in mothers. The emphasis of the model is more on high technology that leads to the loss of human care. • Labeling of mothers with diagnosis rather than being known as a patient with needs to be attended to. • At the same time, Pearson et al. (1998:37) affirmed that the biomedical model is well developed and undoubtedly gives direction to midwifery practice, which is useful.
Lazarus (1994:31) supported the above authors when stating that, in biomedicine, the control is limited by power held by the medical profession. The doctor-patient relationship is asymmetrical, power thus becomes domination and one actor is more autonomous and the other more dependent. The pressure from society and increased understanding of human nature through the Patients’ Charter and Batho-Pele Principles have highlighted the restrictive nature of the biomedical model, the alternative approach being the provision of womancentered care. The Batho-Pele Principles seek to introduce a customer-focused approach that aims to put pressure on systems, procedures, attitudes and behaviour within the childbirth units and re-orient the attending midwives in the customers’ favour, an approach which put people first (Department of Public Service and Administration, 1997). It was further indicated that this does not necessarily mean introducing more rules and centralized processes, or micro-managing service delivery activities. Rather, it involves creating a framework for delivery of public services which treat citizens more like customers and enable them to hold public servants to account for the services they render. The White Paper on the Transforming Service Delivery (1999) and the Department of Public Service and Administration (1997) through the eight Batho-Pele Principles (consultation, service standard, courtesy, access, information, openness and
4
transparency, redress and value for money) aim at improving the entire standard of the public service and effective service delivery. Services should be based on a customer-orientated framework. These principles will be integrated within the framework of this study as follows:
• Midwives are to consult mothers about the level of midwifery care to be received and, where possible, should give (allow) involvement and support choices about the services that are offered (consultation). • Mothers should be told what level and quality of midwifery care (intervention are to be provided so that they would be aware of what to expect (service standard). • Mothers are to be treated with courtesy and consideration; they should be allowed to practice their preferences during childbirth (courtesy). • Midwives should allow all mothers equal access to personal control and decision-making (access). • Mothers should be given full and accurate information about the childbirth process and midwifery care which they are entitled to receive (information). The Department of Public Service and Administration (1997) indicates that the importance of the public service delivery lies in the need to build confidence and trust between the provider (midwife) and the user (mother) through openness and transparency.
Sandall (1995:201) and Midmer (1992:216) were in support of customer-oriented service delivery when they pointed out that the philosophy and focus should shift from technologization to personalization, and to building of the paradigm of woman-centered practice that will be based on equal partnership between mothers and attending midwives. This study will be conducted in one hospital, Limpopo Province. Thus far a limited number of studies were conducted to examine the experiences of childbirth by
5
mothers and their attending midwives. The findings of this study will be integrated within the Batho-Pele Principles in order to develop a childbirth model and to formulate the criteria for care that will be utilized by the attending midwives in order to facilitate mutual participation when providing care during childbirth.
1.3 PROBLEM STATEMENT The challenges with the utilization of the biomedical model are that attending midwives tend to continue to view mothers as physical beings and pay little attention to the wider characteristics of human nature. Mothers seem to have limited powers compared to their attending midwives who focus mainly on completing certain tasks before handing over the report to the next midwife on duty, and thus little effort is expended to meeting the needs of mothers as individuals. Once mothers seek the midwifery care during childbirth, they are expected to follow set standards and midwifery protocols, because the midwives follow set standards of procedures to monitor and regulate physiological developments. While these policies and procedures might make sense from the standpoint of midwifery care and possibly also reflect the priorities dictated by biomedical model, they do not always manifest the experiences, needs and priorities of mothers during childbirth.
1.4 RESEARCH QUESTIONS • What are the mothers’ experiences of childbirth? • What are the experiences of the midwives in managing mothers during childbirth?
1.5 PURPOSE AND OBJECTIVES OF THE STUDY The purpose of the study will be to explore and describe experiences of mothers during childbirth and those of midwives on managing mothers during childbirth in one hospital, in the Limpopo Province. The findings of the study will be used to develop a midwifery model and to formulate criteria for midwifery care based on
6
Batho-Pele Principles. The model will be utilized to assist the attending midwives in the facilitation of mutual participation when managing mothers during childbirth. The criteria will be used as an institutional self-evaluation tool to enhance the implementation of the Batho-Pele Principles. In order to achieve this purpose the following objectives are set: • Identify and describe the experiences of childbirth by mothers. • Describe the management of the childbirth process by the attending midwives. • Develop a midwifery care model for attending midwives in a Tertiary Hospital, in the Capricorn district of the Limpopo Province. • Formulate criteria for midwifery care.
1.6 PARADIGMATIC PERSPECTIVE The researcher believes that no research is free of value and that the value will direct her thinking and activities (Botes, 1993:12).
1.6.1 Meta-Theoretical Assumptions The meta-theoretical statements of the Batho-Pele Principles (Department of Public Service and Administration, 1997) will be used as a frame of reference as described in Chapter 6. Within this framework, the emphasis will be on putting mothers first by facilitating mutual participation during childbirth.
1.6.1.1 Theories and Models The researcher will enter the field without any preconceived ideas by using ‘bracketing’ and ‘intuiting’. A thorough search of theoretical literature on womencentered care during childbirth will be done after data analysis for control of the research results.
7
1.6.1.2
Definitions of Concepts Used In This Study
1.6.1.2.1 Experiences Experience is an event or circumstances undergone or lived through (Oxford English Dictionary, 1999). In this study experiences shall refer to all the circumstances that take place between the mother and a midwife during childbirth.
1.6.1.2.2 Childbirth Childbirth is a process of giving birth to the child (Oxford English Dictionary, 1999). In this study, childbirth shall refer to the process when a mother give birth to a child, which includes the first, second, and third stages of labour.
1.6.1.2.3 Biomedical Model Biomedical model refers to the model on which nurses base their practice and view patients as biological beings and pay little attention to the wider characteristics of human nature (Pearson et al., 1998:27). In this study biomedical model shall refer to the midwife taking full responsibility for controlling the childbirth process without the mother participating and sharing responsibility. The emphasis is thus on the management that focuses on detection of complications, it devalues how the mother experiences childbirth and how she would like to be treated.
1.6.1.2.4 Woman-Centred Care Skinner and Roch (1995:286) indicated that the philosophy of woman-centered care is based on the belief that childbirth is a normal life event, with autonomy, self care and independence. It is viewed as the prerogative of a woman to have the right to all information to make informed choices. However, Rush (1997:1) and ACMI (2001:1) asserted that woman-centered care is a concept that implies that the primary focus of care is on woman’s individual and unique needs, experiences,
8
expectations and aspirations. It is a multidimensional, dynamic process of providing safe, skilled and individualized care during childbirth. It responds to the physical, emotional and psychological needs of the mother. In this study woman-centered care shall refer to customer-oriented care, where the midwives consult mothers about the level of care they receive and encouragement of involvement and support choices about services that are offered. Mothers are allowed to practice their preferences, equal access to personal control and decision-making. Mothers ought to be given full and accurate information about childbirth and midwifery care they are entitled to receive.
1.6.2. Methodological Assumptions Botes (1994) indicated that the purpose of nursing research is functional. This implies that nursing research entails mainly applied research, which addresses the current midwifery problems experienced by childbearing women in South African community and provide solutions to such problems. This does not imply that basic research is not relevant, since applied research is based on basic research.
1.7
RESEARCH METHODOLOGY
1.7.1 Research Design and Method Both the qualitative and quantitative designs will be chosen for this project, as the focus will be on exploring and describing the experiences of childbirth by mothers and their attending midwives. The method will be descriptive, contextual and inductive. The findings gathered through participatory observation, visual analog scale and from interviewing mothers and their attending midwives will be utilized to develop a childbirth model and to formulate criteria midwife care. The criteria will be used as an institutional self-evaluation tool to enhance the implementation of the Batho-Pele Principles in childbirth units.
9
1.7.2
Data Collection
Permission to gain entry into childbirth units will be obtained following approval from the Ethics Committee of Rand Afrikaans University, Provincial Department of Health, and the hospital concerned. Once approval has been obtained, the project will be explained to the unit managers, attending midwives and mothers of the obstetrical and postnatal wards. The study will be conducted in the obstetric (labour) unit to observe the interaction between mothers and their attending midwives and the care provided by the attending midwives when mothers experience childbirth. Interviews for the attending midwives will take place in the obstetric unit and for mothers in the postnatal unit. The researcher will establish ongoing rapport with the mothers and attending midwives in order to gain trust. Informed consent will be obtained from mothers and their attending midwives. The pilot study will be conducted in the same context in order to investigate the feasibility of the study and to detect possible flaws in the data collecting instrument. When collecting data, the researcher will use different data collection methods for both mothers and their attending midwives. Combining different data collecting methods (triangulation) will complement each other by maximizing quality of data and reduce the chance of bias (Hardon et al., 1994:152). These methods will include:
• Unstructured in-depth interviews will be conducted with both groups. For the attending midwives it will be conducted in the obstetric unit rest room for a period not longer than 45 minutes within 24 hours after conducting delivery. For the mothers, it will be held in the postnatal sideward for the approximately 1 hour within 24 hours of delivering the baby.
10
• Participant observations will involve the use of the semi-structured observational guide (checklist) to observe the activities and interactions between the mother and the attending midwife during childbirth. The use of participant observation will give additional and more accurate information on behaviour of people (Hardon et al., 1994:148). The semi-structured observation method will enable the researcher to describe events or behaviour as they occur, with no preconceived ideas of what will be seen (Brink 1996:150-151). In the context of this study, observation will be limited to the interaction between the mother and the attending midwife during childbirth and the midwifery care rendered by the attending midwife when the mother is experiencing childbirth. Observations will be made during the active phase of labour (from cervical dilatation of 3 cm) to the delivery of the placenta. • The Visual Analog Scale (VAS) which is an instrument and a simple scale will be completed by the mothers and midwives independently at the following dilatations of the cervix 0-3, 4-7 and >8 cm. • Unstructured conversations will be held informally throughout labour with mothers and their attending midwives, because these conversations are spontaneous and will emerge out of natural social interaction and will contribute to the depth and richness of information that otherwise would have been difficult to capture through more structured interviews. • Field notes of events and conversations that occur when mothers interact with their attending midwives will be recorded verbatim. The researcher will also interact with mothers to seek clarification and meaning of actions because every act or behaviour has rationale.
These methods will be discussed in more detail in Chapter 2.
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Recording will entail preparing a standardized form to record all actions observed. Recording of field notes form a core of record (Hardon et al., 1994:173). It will entail both the empirical observations and their interpretation. This will include interactions observed, conversations heard, impressions of field settings and their actors and suggestions for future information to be gathered.
1.7.3
Population and Sampling
The population will consist of all mothers that are admitted to deliver their babies and the attending midwives who are providing midwifery care in the obstetric unit of one hospital in the Capricorn district, Limpopo Province. Non-probability, convenience and purposive sampling will be used in the study. Purposive sampling is a type of non-probability, which is collected from a group of respondents chosen for a specific key characteristic (Sells, 1997:172). In this study specific criteria for inclusion will be: • All mothers with term pregnancy (38-42 weeks) and in early active stage of labour (cervical dilatation of 3-5 cm, regular uterine contractions), with the presence of the foetal heart beat. • All attending midwives who have at least two years experience in the obstetric unit who have agreed to participate in the study. The researcher will continue to sample more mothers and attending midwives until theoretical saturation of each new category is reached (Strauss & Corbin, 1990: 188).
1.7.4
Data Analysis
Biographical data of both mothers and the attending midwives and the data obtained through the semi-structured observation guide and the Visual Analog Scale (VAS) will be analyzed quantitatively. The frequency distribution will be used to analyze
12
the data and the data will be presented in the tables and bar graphs. The narrative data from unstructured in-depth interviews, unstructured conversations and field notes will be analyzed qualitatively through the open coding method (Tesch 1990, cited in Cresswell, 1994:155). Data analysis will be discussed in more detail in Chapter 2.
1.8
CONCEPT ANALYSIS
The concept analysis approach as outlined in Walker and Avant (1995) will be adopted (See Chapter 2).
1.9
TRUSTWORTHINESS
The
four
criteria
of
trustworthiness,
namely,
credibility,
dependability,
transferability and applicability, as outlined in Lincoln and Guba (1985:301-318) will be used to establish trustworthiness of this study (See Chapter 2).
1.10 LITERATURE CONTROL One of the chief reasons for conducting a qualitative study is that the study is exploratory, that is, not much has been written about the topic or population being studied, and the researcher seeks to listen to informants and build a picture based on their ideas (Creswell, 1994:21). The literature will be presented at the end of the study for it to become a basis for comparing and contrasting findings of qualitative study (Creswell, 1994:23). The literature control will be carried out after the data have been analyzed. The results, differences and similarities in the narrative form will be compared with the theories and literature.
1.11 ETHICAL CONSIDERATIONS Ethical considerations will be based on DENOSA ETHICAL STANDARDS FOR NURSE RESEARCHERS (1998:2.3.2-2.3.4) and will be outlined in the next chapter.
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1.12 DIVISION OF CHAPTERS The chapters of this study will be arranged as follows: Chapter 1: Orientation Chapter 2: Research Methodology Chapter 3: Discussion of Findings: Mothers’ Experiences of Childbirth Chapter 4: Discussion of Findings: Attending Midwives’ Experiences of Managing Mothers During Childbirth Chapter 5: A Combination of Mothers’ and Attending Midwives’ Findings and the Literature Control Chapter 6: Concept Analysis of Woman-Centred Care Chapter 7: Conclusions, Validation, Limitations and Recommendations of the Study
1.13 SUMMARY In this chapter, the problem to be researched as well as the motivation for the study has been described. The research design and methods of this study were highlighted, followed by the sequential organization of the chapters.
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CHAPTER 2 RESEARCH METHODOLOGY
2.1
INTRODUCTION
Qualitative and quantitative approaches which are exploratory, descriptive, contextual and inductive will be used for this study with the aim of determining the experiences of childbirth by mothers and their attending midwives at one hospital, in the Capricorn district of the Limpopo Province. From the results of the study the main concept (category) will be identified after which a concept analysis, concept and statement synthesis process will be conducted. This will be followed by the development of a childbirth model that would be implemented by attending midwives to facilitate care in childbirth units. Criteria will be formulated which will be utilized as an institutional self-evaluation tool to enhance the implementation of the Batho-Pele Principles in childbirth units. The research methodology evolved as the research step progressed and will include the following: • Research Design and Method • Preparation for Data Collection • Pilot Study • Data Collection Method • Population and Sampling • Data Analysis • Concept Analysis • Concept and Statement Synthesis • Trustworthiness • Ethical Considerations
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2.2
RESEARCH DESIGN AND METHOD OF DATA COLLECTION
The purpose of this part is to describe the research design and methods to be used for data gathering from the participants and to provide a thick description of the concept woman-centered care.
2.2.1 Qualitative and Quantitative Research Designs Qualitative and quantitative research designs will be combined. The qualitative approach seeks understanding and interpretation aimed at generating theory and hypothesis whereas quantitative methods seek explanation aimed at generalization (Foss & Ellefsen, 245:2002). The qualitative research design will be chosen for this project as this approach emphasizes the natural setting. Burns and Groove (1993:777) referred to qualitative research design as a systematic, subjective approach used to describe life experiences and give them meaning. This seems to correspond with what Walker and Avant (1995:99) implied when they defined qualitative research as descriptive in that the researcher is interested in the process, meaning and understanding gained through words. The quantitative research design will further be followed by selecting observable indicators. After acquiring the participants’ responses on these indicators (through observations) a scale will be constructed to serve as a composite measure of the theoretical construct in question In this study the focus will be on exploring and describing the experiences of childbirth by mothers and their attending midwives and to develop the relevant concepts. The design will provide qualitative information that cannot usually be uncovered in surveys or formal interviews whereas the quantitative approach will give a broad, general view of the surface.
2.2.2 Explorative Research design Babbie and Mouton (2001:79) held the view that this method is typical when a researcher examines a new interest or when the subject of the study is relatively
16
new. This design will be used in this study with the aim of gaining insight and understanding of experiences on childbirth by mothers and their attending midwives in the Capricorn district of the Limpopo Province, since no literature attest to this subject.
2.2.3 Descriptive Research design Qualitative research is interested in describing the actions or experiences in detail (thick description). Babbie and Mouton (2001:81) regarded this as attempting to understand the actions in terms of the actors’ own beliefs and context, and further indicated that events in the context will be placed so that they are understandable to the actors themselves. In this study the findings through participatory observation, visual analog scale and from interviews with mothers and their attending midwives will be used. The major concept will be synthesized and analyzed as womancentered care. Criteria for the provision of midwifery care that are integrated within the Batho-Pele Principles will be formulated. The developed model and formulated criteria will facilitate the implementation of the Batho-Pele Principles by the attending midwives and enhance mutual participation between the mothers and attending midwives during childbirth.
2.2.4 Contextual (Idiographic) Research Method The researcher would like to understand the events, actions and processes during childbirth in their context. Babbie and Mouton (2001:272) referred to the contextual research method as understanding the events within the concrete, natural context in which they occur. Contextualizing will be achieved as the study will solely be devoted to understanding the experiences of childbirth by mothers and their attending midwives at Tertiary Hospital in the Capricorn district of the Limpopo Province.
17
2.2.5 Inductive Research Method Babbie and Mouton (2001:273) indicated that the inductive research method begins with an immersion in the natural setting describing events as accurately as possible, as they occur and building the second order constructs. In this study the researcher will be immersed in the obstetrical unit to explore and describe the experiences of childbirth by mothers and their attending midwives. From the findings of the study the researcher will cluster the sub-categories and develop the major category. A concept analysis, synthesis and statement synthesis of the major concept, will be made, followed by a development of a childbirth model and the formulation of criteria for care.
2.2.6
Reasoning Strategies for Analysis and Synthesis
Reasoning strategies that are utilized will include analysis, synthesis and deduction.
2.2.6.1 Analysis In the analysis stage the researcher will dissect the whole into component parts so that they can be better understood. The researcher will then examine the relationship to each other of the individual parts and to the whole (Walker & Avant, 1995:28). Analysis is the classification, refinement or sharpening of concepts and statements. In this research, analysis will be used during exploration and description of concepts relevant to woman-centered care and analysis will also be employed during interviews.
2.2.6.2 Synthesis Synthesis is the process of combining various elements of data into a pattern or relationship not clearly seen before so as to form a new concept (Walker & Avant, 1995:28). In this study, synthesis will be utilized when the experiences relating to
18
childbirth are defined, analyzed, categorized and positioned according to identified relations to form statements. 2.2.6.3 Deduction In deductive logic, two or more premises are used as rational statements to draw a conclusion. In this study, deduction will be employed in the development of woman- centered care childbirth model and the formulation of criteria, based on the findings of the study.
2.3
PREPARATION FOR DATA COLLECTION
Gaining of entry - this will involve obtaining approval from the Ethics Committee of the Rand Afrikaans University, Provincial Department of Health and the hospital. Once the approval has been secured, the project will be explained to the sister-incharge of the wards of the attending midwives and the participating mothers. The study will be conducted in obstetric (labour) and postnatal units. The researcher will gain trust by establishing ongoing rapport with the mothers because the researcher as an advanced midwife and educator will be in the setting over a sustained period of two weeks per month in the clinical area when doing accompaniment of students. This period will be sufficient to develop a meaningful bond with the mothers and their attending midwives. This relationship will facilitate data collection and enrich the data (Muller, 1995:69). Informed consent will be obtained from both mothers and their attending midwives.
2.4
THE PILOT STUDY
The pilot study was conducted in the same context on the limited number of the participants from the same population in March 2003. The population included twelve (12) mothers and six (6) attending midwives. Data collection methods used for mothers and attending midwives included the following: unstructured in-depth interviews, participant observation, visual analog scale, unstructured conversations
19
and field notes. Unstructured in-depth interviews for mothers were conducted in the local (vernacular) language of the mother, audio-taped, transcribed and translated into English. For attending midwives, unstructured in-depth interviews were held in English. The analysis began when the data collection started. This meant that the first day’s observations on interaction were analyzed so that codes and concepts would be generated. Findings of the pilot study guided the researcher on the plan of the main study and assisted in assessing its feasibility. The researcher observed the mothers during childbirth and developed a semi-structured observational guide (checklist). The observation guide used in participant observation and the visual analog scale were further refined during the pilot study. The rationale behind this approach is affirmed by Brink (2001: 174), namely, the purpose of the pilot study is to investigate the feasibility of the proposed study and to detect the possible flaws in the data-collecting instrument.
2.5
DATA COLLECTION
Data to determine the experiences of childbirth will be collected from two groups namely • Mothers • Attending midwives The aim was to determine how mothers experienced their childbirth and how attending midwives experienced nursing the mothers. The observations and visual analog scale were used to compare the mothers and midwives experience with what is been seen in the reality and how the mothers’ needs are being met. The researcher will begin with the collection of the biographical data of the participants before collecting the narrative data (Tables 2.1 and 2.2). The researcher will use different data collection methods. Combining different data collecting methods (triangulation) will complement each other by maximizing quality of data and reducing the chance of bias (Hardon et al., 1994:152). Data collection methods will include the following:
20
• Unstructured in-depth interviews with the aim of determining the experiences of the participants during childbirth. • Participant observation will be done to record the activities and the interaction of the mother and midwife during childbirth. • A Visual Analog Scale (VAS) will be used to compare the pain of childbirth by mothers and the perception by midwives of the exhibited pain in order to determine how midwives interact and respond to the needs of mothers during childbirth. The scale is of merit because of its simplicity and ease of use by the mothers. • Unstructured conversations will be held informally during childbirth since the researcher is of the opinion that these conversations occur spontaneously and will emerge out of natural social interaction, which will contribute to the depth and richness of information that would otherwise be difficult to capture through more structured interviews. • Field notes will include all daily activities, interactions observed, conversations heard and impressions of the field setting and its actors. The findings from the abovementioned methods will attempt to answer the research questions set out in Chapter 1.
2.5.1 Data Collection Method for Mothers The biographical data of mothers recruited for the study (Addendum 3). 2.5.1.1 Unstructured In-Depth Interviews The question that would be directed to mothers is: “Could you please tell me about your experiences of childbirth in this hospital?” The unstructured in-depth interview for the mothers will be conducted by the researcher (who is an advanced midwife) in the postnatal sideward, for not more
21
than 1 hour, within 24 hours of delivery. This will allow the drawing of categories of meaning by eliciting what mothers think, how one’s experience compares with another’s and to map out how interactions influence behaviour (participation) (Hardon et al., 1994:188). During the unstructured in-depth interview an openended question will be used. Sells (1997:172) indicated that an open-ended question should start with a broad, non-directive question that allows informants to say whatever they think with minimum guidance from the interviewer. Probing will be used to gain an understanding of critical issues (De Vos, 1998: 318).
The following examples of probing will be used: Tracking:
Allowing mothers to tell the story in their own way and freely through verbal and non-verbal communication, and by showing interest.
Clarification:
The researcher will ask for more information, that is: Can you please tell me more about…? or What do you mean when you say…?
Reflective Summary:
The interviewer will repeat the probing to make sure that the interviewees are correctly understood, for example: What you say is…? Do I understand you correctly when I say that …? In other words, you feel that … And, is it therefore your opinion that…?
As an ethical consideration the permission to use an audio-tape recorder and conduct note taking during interview will be obtained from mothers. The tape recorder, with the permission of the participants, will be positioned where it can capture their dialogue. The researcher will manage and ensure that the tape recorder have cassettes ready at all times.
2.5.1.2 Participant Observation
22
Participant observation will be done in the obstetric unit, when the mother is experiencing childbirth, to discern the activities and interactions of the mother and midwife during childbirth. The researcher will disclose her identity and the purpose of the study to other participants keep discussions more focused and since it is an ethical consideration. According to Savage (2000:326) participant observation attempts to derive knowledge by using all senses. Participation in midwifery care with attending midwives and conversation with mothers during labour, will give additional, more accurate information on behaviour of people (Hardon et al., 1994:148). Recording of observations on the semi-structured guide will be limited to midwifery care, when the mother is responding to pain, interaction between mothers and midwives during childbirth. All these will be carried out during the active phase of labour (from cervical dilatation of 3 cm) to the delivery of the placenta (Addendum 5). The first objective of utilizing this method will be to determine how the mother reacts to childbirth and how midwives react to the mother’s response to childbirth. The second objective is to establish what interaction and intervention take place between the mother and a midwife during childbirth. Hardon et al., (1994:169) were of the opinion that participant observation is essential for checking and evaluating key informant data. When using participant observation, data will be collected through observation and interviews. Participant observation will be used as this method will enable the researcher to describe events or behaviour as they occur, with no preconceived ideas of what will be seen (Brink, 1996:150-151).
2.5.1.3 Visual Analog Scale (VAS) The visual analog scale (VAS), an instrument with clear instruction, will be given to mothers and attending midwives independently during the active phase of labour, that is, at 0-3 cm, 4-7 cm and >8 cm dilatation. The researcher will give the tool to the mother and to her attending midwife at 0-3 cm cervical dilatation, after completion the tool will be collected by the researcher and the same procedure would be followed at 4-7cm and >8 cm cervical dilatation. Throughout labour, all
23
the assessments will be completed without reference to the previous rating. The aim will be to compare the childbirth pain experienced among mothers and the exhibited pain as perceived by midwives. This will assist in determining how midwives respond to the mother’s childbirth needs. The scale will also be used because it is simple to be used by mothers (Addendum 6).
2.5.1.4 Unstructured Conversation The researcher who is an advanced midwife will interact with mothers to seek clarification and meaning of actions during childbirth because every act or behaviour has rationale. The unstructured conversation will be done informally, throughout labour, because these conversations are spontaneous and will emerge out of natural social interaction and will contribute to the depth and richness of information that would otherwise have been difficult to capture through more structured interviews.
2.5.1.5 Field Notes Field notes of events and conversations that occur when mothers interact with their attending midwives will be recorded verbatim. Field notes will be taken during interviews as validation of taped comments. The recording will be done in a small notebook that easily fits in the pocket, and will include the empirical observations and their interpretations, daily activities, interactions observed, conversations heard, impressions of field settings and its actors and suggestions for future information to be gathered.
2.5.2 Data Collection Method for Attending Midwives
The biographical data of attending midwives (Addendum 4).
24
Data collection for the attending midwives will be the same as those for mothers and will include biographical data and the following methods: • Unstructured In-Depth Interview • Participant Observation (especially the interaction during childbirth) • Visual Analog Scale (VAS) • Field Notes
The question directed to attending midwives will be:
“Could you please tell me about your experiences of managing mothers during childbirth?” This central question will be asked to attending midwives in order to determine how they meet the needs of the mothers during childbirth. Unstructured in-depth interviews will be conducted by the researcher in the labor ward in a rest room (quiet place), for not more than 45 minutes and within 24 hours of conducting delivery. The interview process will be carried out in the same manner as outlined for mothers. Recording of field notes form a core of record (Hardon et al., 1994:173). Notes will be made with verbatim (substantial) information and the details will capture promptly. A blank page with wide margins will be used to make comments on the right-hand side and the left-hand side will be used for coding notes, the dates and places of the events will be indicated. The researcher will prepare a note-taking recording form where all actions observed will be recorded.
2.6
POPULATION AND SAMPLING
2.6.1 Target Population of Mothers Mothers admitted to a Hospital will be presumed as key participants. Mothers will be recruited from the obstetric and the postnatal units of the one hospital in the
25
Capricorn district, Limpopo Province. This hospital will be utilized because it is an obstetrical referral hospital for all six districts in the Limpopo Province, and it also renders childbirth services for the students from the University of the North, Limpopo Nursing College students and Medical University of South Africa. The population will consist of all mothers admitted to deliver their babies in the tertiary hospital of the Capricorn district, Limpopo Province. The study will be conducted in the obstetrics and postnatal units. Non-probability, convenience and purposive sampling will be used. Purposive sampling is a type of non-probability sampling in which data are collected from a group of respondents chosen for a specific key characteristic (Sells, 1997:172). The researcher will enter the obstetric unit and sample the available mother in labour (3 cm cervical dilatation) and the attending midwife who is providing midwifery care. The data will be collected from this pair as explained under 2.6.1 and 2.6.2, that is, visual analog scale and participant observation guide. For the attending midwives, the unstructured interviews will be conducted in the obstetric unit (side ward) within 1 hour of conducting delivery. In the postnatal unit, the mother who was sampled and observed during delivery will be followed-up for the in-depth unstructured interview. In this study the specific criterion for inclusion was: • All mothers with term pregnancy (38-42 weeks), should be in the early active stage of labour (cervical dilatation of 3-5 cm, regular uterine contractions) with the presence of foetal heart beat. Mothers with intrauterine deaths were excluded because such variables may influence the results. 2.6.2 Target Population for Attending Midwives Attending midwives at a hospital will be presumed as key participants. As with mothers, the attending midwives will be recruited from the obstetrical ward of the tertiary hospital in the Capricorn district, Limpopo Province. The population will
26
consist of all attending midwives who are providing midwifery care in the obstetrical ward. The sampling will be done in the same manner as that for mothers. The researcher will include the attending midwife who is providing midwifery care to the sampled mother during that period.
In this study the specific inclusion criterion will be: • All midwives who have at least two years experience in the obstetrical unit and who has agreed to participate.
For in-depth unstructured interviews in a qualitative research design, the number of participants interviewed is not as important as the inner world of the interviewee which should be described as completely as possible. The researcher will continue to sample more mothers and attending midwives until theoretical saturation of each new category is reached. According to Glaser and Strauss (1978) in Strauss & Corbin (1990:188), theoretical saturation means that no new or relevant data seem to emerge regarding a category, the category development is dense and the relationship between categories are well established and validated.
2.7
DATA ANALYSIS
2.7.1 Quantitative Data Analysis The biographical data for both mothers and attending midwives and the data obtained through the semi-structured observational guide and visual analog scale will be analyzed quantitatively by using frequency distribution. For biographical data, the focus will be on the description of the sample population, for example, age, parity, educational level, ethnic group, social class, religion, delivery outcome, pain relief during childbirth, presence of companion, participation in childbirth
27
preparation classes and transfer from other hospital and these will be presented in Tables 2.1 and 2.2. The data obtained through the semi-structured observational guide will focus on the interaction between the mother and the midwife during childbirth (communication and informational support) and midwifery care provided when mother experiences childbirth (supportive care and emotional support activities) this data will be presented in bar graphs. The data obtained through the visual analog scale will compare the childbirth pain experienced among mothers and the exhibited pain perceived by midwives. The data aim to determine how attending midwives respond to mothers’ childbirth pain and will be presented in bar graph.
2.7.2 Qualitative Data Analysis The narrative data from unstructured in-depth interviews, unstructured conversation and field notes will be analyzed qualitatively through open coding method. Tesch’s (1990) procedure will be used as the method of choice for data analysis. Tesch’s (1990 cited in Creswell, 1994:155) method involves the following steps: 1. The researcher will listen to the tapes to test the sense of the whole, to internalize the content and then transcribe the content verbatim. She will read carefully through all transcripts to get a sense of the whole. 2. The researcher will pick one interview randomly, read through it, asking self the following questions: What is it about? What is the underlying meaning? The researcher will use the tape that answers the question: ‘What are your experiences of childbirth in this hospital?’ and ‘What are your experiences of managing mothers during childbirth?’, and repeatedly listen and jot down ideas in the margin as they come to mind. According to Starrin, Dahlgren, Larsson and Styrborn (1997: 36) the researcher must ask the following questions that are related to the data:
28
• What does the data say? • What categories indicate the event? • What category or characteristic within the category indicates this event? • What kind of concepts can I use to describe this? 3. After the researcher has completed the task for all interviews, she will make a list of all topics covered, cluster together similar topics, form topics in columns as major topics, unique topics and leftovers. At this level, the researcher is synthesizing and analyzing the information. 4. The researcher will find the most descriptive wording of topics and will turn them into categories, the total list of categories will be reduced by grouping them into related entities. Lines will be drawn between the categories to show interrelationships formed between and among concepts and statements. 5. A final decision about abbreviation of each category will be made and alphabetized. 6. The data which belong to each category will be assembled and a preliminary analysis performed. The researcher will synthesize the relationship statement from concepts to provide links between and among concepts. 7. If necessary, the existing data will be re-coded. The researcher will develop strategies for testing or confirming findings to proof their validity. As meaning emerge from the data, this will be tested for their plausibility/confirmability, that is, validity. Referring to field notes, lengthy argumentation with colleagues, use of triangulation and looking for negative case will be done to review the findings. This will be described in detail under trustworthiness. The researcher and an independent coder will analyze the transcriptions independently. The independent coder will be a supervisor
29
experienced in research and in conducting qualitative data analysis. During data analysis, bracketing will be considered. A protocol describing the method of data analysis and raw data will be provided to the independent coder; no categories will be sent. Thereafter, a meeting will be held for consensus discussion on the categories reached independently. 2.8
CONCEPT ANALSYIS
Concept analysis will be conducted on the major category (concept) that emerged after data analysis. An eclectic approach to concept analysis will be adopted incorporating the methods advocated by Walker and Avant (1995). Based on the descriptions by Walker and Avant (1995) and Rossouw (2001), concept analysis involves the following steps: • Select a concept • Aims of analysis • Identify uses, characteristics or connotations of the concept • Develop model case of the concept • Identify the antecedents and consequences of the concept • Define the empirical referents 2.9
DEVELOPMENT OF A CHILDBIRTH MODEL
The conceptual model will be developed by utilizing the Dickoff, James and Wiedenbach’s (1968) survey list in Madela-Mtla (1999:69). The list will include agent, recipient, procedure, context, dynamics and terminus/goal. The development of a model will describe the structure and process of the model. The evaluation of the model/ theory will be performed essentially as described by Chinn and Kramer (1995:134-135). The development of the model will be presented in detail in Chapter 6.
2.10
TRUSTWORTHINESS
30
To validate the research methodology, credibility, dependability, transferability and applicability, criteria according to Lincoln and Guba (1985:301-318) will be applied to establish trustworthiness of the study.
2.10.1 Credibility Looking at the activities that increase the probability that credible findings will be produced
ensures
truth-value
through
prolonged
engagement,
persistent
observation, triangulation, referential adequacy, peer debriefing and member checks. • Prolonged engagement is the investment of sufficient time to achieve certain purposes, testing for misinformation introduced by distortion of self or of the respondents and building trust (Lincoln and Guba, 1985:302). In this study the researcher will stay in the field until data saturation occurs. • Persistent observation will be achieved through participant observation. •
Triangulation is applied in order to gain information from different sources (Lincoln and Guba, 1985:305).
In this study the use of different data
collection methods, namely, unstructured observation, semi-structured interview and field notes to cross-check the collected data will ensure credibility. • Referential adequacy through the use of audiotape to record findings will provide a suitable record. • Peer debriefing through the discussion with the senior peer who is outside the context of the study but who has a general understanding will be consulted. • The researcher will conduct member checks, that is, go to the source of the information (participants) to verify both the data and the interpretation to assess correct obvious errors and allow for provision of additional
31
information. The participants will be requested to validate the truth and to confirm the results.
2.10.2 Dependability According to Babbie and Mouton (1998:277), dependability refers to an inquiry that must provide its audience with evidence that if it were to be repeated with the same or similar respondents in the same context its findings would be similar. In this study dependability will be achieved through an inquiry audit where an auditor (reviewer) will examine documentation of critical incidents (documents and interview notes) and products (findings, interpretations and recommendations) and attest that these are supported by data.
2.10.3 Transferability Transferability means the extent to which the findings can be applied in other contexts or with other respondents (Babbie & Mouton, 1998:278). In this study transferability will be attained through thick description of research methodology. The researcher will collect sufficiently detailed descriptions of data in context and report them. The purposive sampling will be used to maximize ranging of specific information that can be obtained from and about the context by purposely selecting locations and participants that differ from one another.
2.10.4 Confirmability Confirmability is a measure of the degree to which the findings are the product of the focus of the inquiry and not the biases of the researcher (Babbie & Mouton, 1998:278). In this study confirmability will be tested through the involvement of an experienced supervisor who, as an independent coder will analyze transcriptions, review raw data, tape recorded data, written field notes, documents and results independently. Checking for the representativeness of data, that is, whether the researcher has indeed interviewed all categories of participants needed to get a
32
complete picture of the topic, will be examined by referring back to the in-depth interview discussions because all participants should have contributed. The independent coder, will also review open-coding (analysis) products, axial (synthesis) products, selective and theoretical coding materials relating to intention (proposals) and instrument development information. Doctoral committees and seminars will be attended to establish the truth-value of the data.
2.11 LITERATURE CONTROL One of the chief reasons for conducting a qualitative study is that the study is exploratory, that is, not much has been written about the topic or population being studied, and the researcher seeks to listen to participants and build a picture based on their ideas (Creswell, 1994:21). The literature will be presented at the end of the study as a basis for comparing and contrasting findings of the qualitative study (Creswell, 1994:23). The literature control will be carried out after the data have been analyzed. The results, differences and similarities in the narrative form will be compared with the theories and literature. In the context of this study, concepts will be identified from the data obtained and the major concept synthesized, analyzed and the conceptual model and criteria for woman-centered care that are integrated within the Batho-Pele Principles would be developed and formulated. The model will attempt to assist the attending midwives in the facilitation of care within the childbirth units. The formulated criteria will be utilized as an institutional self-evaluation tool to enhance the implementation of the Batho-Pele Principles in childbirth units at the tertiary hospital at the Capricorn district of the Limpopo Province.
2.12 ETHICAL CONSIDERATIONS Ethical considerations will be based on the DENOSA ETHICAL STANDARDS FOR NURSE RESEARCHERS (1998:2.3.2-2.3.4).
33
2.12.1 The Quality of the Research In this study, the nurse researcher will demonstrate the accountability and ability of executing the research process by adhering to the highest possible standards of research planning, implementation, evaluation and reporting of research. The quality will be ensured by writing a good research proposal, which will be submitted to the Ethics Committee of the Rand Afrikaans University and to the Limpopo Province, Department of Health Research Committee for approval. The research will be conducted after the permission had been granted and the researcher will report all data and publish the results. The researcher will make available the contact details to the participants for questions regarding the research project.
2.12.2 Confidentiality and Anonymity The researcher will protect participants’ identity, privacy, worth and dignity by ensuring that no connection between the participant and the research data can be made.
2.12.3 Right to Self-Determination Informed consent will be obtained from the relevant participants and authorities. Permission to use a tape recorder will also be requested. Transparency will be upheld in terms of the objectives of the research, type of data to be collected, method of data collection and possible benefits to the authority and participants. There will be no victimization of participants who refuse to participate in the research, or who withdraw during the course of the study.
2.13 SUMMARY In this chapter, a qualitative, explorative, descriptive and contextual research design, specific to childbirth unit of a Hospital was described. The sample will be selected from mothers who are undergoing the childbirth process and the midwives who are
34
providing care to mothers during childbirth. After data analysis the major concept will be synthesized, analyzed and the model and criteria for care that are integrated within the Batho-Pele Principles would be formulated. The developed model will attempt to assist the attending midwives in the facilitation of mutual participation during childbirth. The formulated criteria will be utilized as an institutional selfevaluation tool to enhance the implementation of the Batho-Pele Principles in childbirth units at a hospital at the Capricorn district of the Limpopo Province.
CHAPTER 3 THE DISCUSSION OF RESEARCH FINDINGS: EXPERIENCES OF CHILDBIRTH BY MOTHERS
3.1
INTRODUCTION
Chapter 2 of this thesis dealt with a detailed description of the research design and method. Chapter 3 introduces the concept identification of the research and will focus on the discussion of the results of interviews with the mothers regarding their experiences during childbirth (Mother’s Transcript, Addendum 3). Data were collected through fieldwork at the tertiary hospital’s obstetric and postnatal units in the Limpopo Province. Data were collected until saturation was reached. The target population was all the mothers admitted to deliver their babies in the tertiary hospital. A criterion for selection was described in Chapter 2. Sampling was purposive and consisted of 24 mothers (Table 3.1). In this study the focus will be on discussing the results of interviews conducted with mothers regarding their experiences of childbirth at the tertiary hospital in the Capricorn district of the Limpopo Province.
35
Data collection methods used was as follows: • The unstructured interviews were based on one central question: “Could you please tell me your experiences of childbirth in this hospital?” Probing as a communication strategy as outlined in De Vos (1998:318) was used to source more data from mothers. • Participant Observation, using observation guide (Addendum 5) • Visual analog scale (Addendum 6) • Unstructured conversation Table 3.1: Profile of Mothers Recruited to the Study (n =24) Characteristic 1.
2.
3.
4.
5.
6.
7.
8.
9.
Age in Years on Your last Birthday 12-16 17-21 22-26 27-31 32-36 37+Parity Primigravida Para 2-3 Para 4-5 Para >6 Delivery Outcome (Exclude 2 Foetal Deaths) Normal Vaginal Delivery Forceps or Vacuum Extraction Delivery Caesarean Section Duration of Labour 2-4 Hours 5-8 Hours >9 Hours Pain Relief During Childbirth Pharmacological Non-pharmacological Cultural\Ethnic Group Northern Sotho Tsonga Venda Zulu Xhosa Tswana Swazi Asian Whites Others Family Status Married Single Divorced Widow Religious Affiliation Luthern Dutch Reformed Church (NG) Zion Christian Church (ZCC) Apostolic Church Others Educational Level Never Literate Primary School Literate
No 1 6 8 4 2 3 13 7 0 4
19 0 5 2 4 18 3 21 15 4 2 0 0 2 0 0 0 1 (Mozambiquan) 10 14
2 2 10 3 7
2 5
36 Secondary School Literate Tertiary Institution 10. Companion Present Yes No 11. Participation in Childbirth Preparation Classes Yes No 12. Transfer from Other Hospital Yes No
3.2
9 8 0 24 1 23 5 19
DISCUSSION OF RESULTS: MOTHERS
The results from the experiences of mothers during childbirth revealed five (5) major categories, namely: 1. Mutual Participation and Responsibility Sharing 2. Information Sharing and Empowering 3. Open Communication and Listening 4. Accommodative/Non-Accommodative Midwifery Actions 5. Maximizing of Human and Material Infrastructure The identified categories will be discussed below. Table 3.2 represents an overall picture of categories and themes.
3.2.1 CATEGORY 1: MUTUAL PARTICIPATION AND RESPONSILITY SHARING In this category five themes were identified. Each theme will be discussed separately. Table 3.3: Category 1: Mutual Participation and Responsibility Sharing THEMES A. Participation/Lack of Participation B. Responsibility/Lack of Responsibility in Own Care
37 C. Dependency D. Decision Making/Lack of Decision Making E. Facilitation/Promotion of Participation
Table 3.2: Categories and Themes 1.
2.
3.
4.
5.
Mutual
Information
Open
Accommodative
Maximize Human
Participation and
Sharing and
Communication
/Non-
and Material
Responsibility
Empowering
and Listening
Accommodative
Infrastructure
Sharing
Midwifery Actions
A.
A.
A.
A.
Participation/Lack
Limited
Verbal/Hindered
Guide, Support
of Participation
Information About
Verbal
and Respect
Childbirth Issues
Communication
Choices
A. Shortage of Staff
and Available Childbirth Options B.
B.
B.
Responsibility/Lac
Autonomy/Lack of
Trust/Lack of Trust
Presence of a
Labour Ward
k of Responsibility
Autonomy
Relationship
Companion
Infrastructure
B.
Sharing C. Dependency
C. Informed Choices
C.
C.
Physical/Lack of
Conflicting
Physical Comfort
Expectations
Measures and Emotional Support D.
D.
D.
D.
B.
38 Decision
Empowering/
Authoritative
Unrealistic
Making/Lack of
Powerlessness
Approach (Limited
Choices
Decision Making E. Facilitation/Promot ion of Participation
Human Rights
38
3.2.1.1 Theme A: Participation/Lack of Participation “To have a share, to take part in something” (Oxford English Dictionary, 1999:670). In this study participation will refer to the situation where the midwife will work collaboratively and interdependently with the mother into the exploitation of all available options/services that are offered during childbirth. There were variable responses, according to mother participants from the interviews. Mothers felt that they were not involved in their care during childbirth as supported by the following quotes from interviews: Miss E¹
“Midwives know what to do and how to care for us during labour but at times I just felt I’m not involved because I’m just told what to do without being asked. I don’t want to be restricted; I wanted to be up and about alternating with resting.”
Miss H¹
“I was not involved and not informed about my progress, midwives will examine me and I will only overhear them giving each other the report, but not telling me so that I can participate.”
Miss K¹
“Sometimes other midwives are not friendly, maybe if they can change their attitudes … and be friendly, then we can be free to participate as we prefer”
Miss I¹
“Yes, I felt I participated in my care because I had a prolonged labour and I told the sister that I won’t deliver and they must insert me a drip and take me to the operation. Indeed, she called the doctor who examined me and I was done an operation.”
Miss J¹
“To me midwives were Ok … because they were allowing me to be up and about as I preferred.”
39
3.2.1.2 Theme B: Responsibility/Lack of Responsibility in Own Care “Legally and morally liable for own care. Obliged to make decisions in own care” (Oxford English Dictionary, 1999:439). In this study responsibility shall refer to when the mother take an active interest in and become involved in self-care. Through self-determination, the mother progressively develops responsibility for self, belief in potentialities, and adjustment toward self-reliance and independence. During childbirth mothers displayed limited initiative in taking responsibility for their own care. They were not taking responsibility in own care as supported by the following quotes: Miss A¹
“I was just keeping quiet and waited for the midwife to come and examine me … my mother told me that I must keep quiet because childbirth pain will be relieved by delivering a baby, nothing can be done to relieve it (laughing) … she told me to pretend as if I don’t feel the pain, but to communicate to the midwives.”
Miss C²
“I think yes … I do want to take responsibility, during childbirth I think there is nothing that I can say because I listen to all what the sisters say, they know their work and they assist us a lot.”
Miss D²
“During childbirth I was following all the instructions as was instructed by the sister because the sister has knowledge and I’m ill.”
Miss F¹ &
“Hmm … I was quiet, I will persevere and I will wait for the midwife
Miss G²
to examine me.”
Miss F¹
“No, during childbirth I don’t have anything to say, but I must listen to all what midwives says.”
40
3.2.1.3 Theme C: Dependency “Depending on somebody for help and support” (Oxford English Dictionary, 1999:131). In this study dependency shall refer to the process taking place during childbirth where the mother is not participating in her care, but put herself in the hands of the attending midwife for care. It was indicated from the interviews with midwife participants that mothers put themselves in the hands of midwives because they say midwives know best and mothers don’t know. It was evident from the interviews held with mothers that they were depending on midwives during childbirth. The following quotations support this observation: Miss A¹ &
“Yes midwives know their work with the help of God, they are
Miss I¹
trained and they tell me what to do”.
Miss B¹
“(Quiet …) no I can’t decide because I don’t know, sisters and doctors know exactly what is happening. They are able to determine complications early and prevent them.”
Miss D² &
“There is nothing that I can do or say, the sister must tell me what
Miss E²
to do and I don’t see myself having to tell them what to do. “I didn’t have specific choices during childbirth, but I was doing and listening to all what the midwives were saying I must do.”
Miss H¹
“(Laughing) Hmm … you know because it was the first-time, I was depending on the midwife to tell me what to do, then I’ll follow by doing whatever she tells me to do. Hmm … childbirth pain is natural; nothing can be done to relieve it. But because the midwives are trained, they know their work best … maybe they must teach us what they know that can assist because we depend to them. ”
41
3.2.1.4 Theme D: Decision making/Lack of Decision-Making “The ability to judge and act accordingly” (Oxford English Dictionary, 1999:137). In this study decision-making shall refer to the process whereby the mother indicates her childbirth choices, preferences to the midwife. The following excerpt from the interviews of mothers, shows clearly that some mothers were willing to take part in decision-making. This was characterized by the following statement: Miss A²
“I would be very happy to be involved in decision-making during childbirth, but this was not the case and we need to be given more information on all issues relating to childbirth because if we are having information we can decide and make informed choices.”
3.2.1.5 Theme E: Facilitation/Promotion of Participation “A process of making easy, lessening of difficulty” (Oxford English Dictionary, 1999:180). In this study facilitation will refer to the process of integration of the Batho-Pele Principles within the woman-centered childbirth model. The following is the summary derived from the interview transcripts of mothers, revealing the opinions of mothers on promoting/facilitating their participation in childbirth: If midwives can avail themselves throughout the childbirth and give me detailed information on what to expect, after examining me to tell me the progress of my labour, I think this will enhance my participation and allay my anxiety. Midwives should display a friendly attitude, be approachable, patient, and not to scold us and have respect. This will allow us not to be afraid to voice our preferences. Midwives should ask us what we want and not to always tell us what we want, we understand that they are trained as professionals.
42
Midwives should allow us to take decisions especially if our decisions are not interfering with their care, like allowing our partners if they prefer to be with us during childbirth. They must also listen, and empathize with us when we feel pain, and treat us as they would like to be treated and give us advice. I think if on admission we can draw a contract that will clarify our expectations; this will facilitate an open communication during childbirth.
3.2.2 CATEGORY 2: INFORMATION SHARING AND EMPOWERING Table 3.4: Category 2: Information Sharing and Empowering THEMES A. Limited Information About Childbirth Issues and Available Choices/Options B. Autonomy/Lack of Autonomy C. Informed Choices D. Empowering/Powerlessness
3.2.2.1 Theme A: Limited Information on Childbirth Issues and Available. Childbirth Choices “Facts told or discovered” (Oxford English Dictionary, 1999:262). In this study information on childbirth issues and available choices shall refer to the quality information that is given to the mother by the attending midwife during childbirth. During the interview, mothers appeared to have limited knowledge and information about childbirth issues. Mothers also did not have a good understanding of the available options which they can exercise as the right to choose during childbirth. The following excerpts from the interviews were cited with regard to available options, and childbirth issues: Miss A¹, Miss G¹ & Miss G²
“During childbirth I was not informed and I didn’t know that I can indicate the preferences that I had, like having a companion.”
43
“You know, this is my 7th child, but I never knew anything with
Miss I¹
regard to availability of indicating one’s preferences.” Miss B¹,
“(Laughing …) I don’t know what to expect and what is going to
Miss F² &
happen during childbirth, the midwives and doctors know exactly,
Miss H¹
they are able even to determine the complications early and to prevent them.
Miss L¹
“My midwife was telling me to breathe in and out but I didn’t know why.”
The lack or poor availability of information about childbirth issues tend to subject the mothers to limited decision making capacity and increased dependency on the midwives.
3.2.2.2 Theme B: Autonomy/Lack of Autonomy “Right of self, freedom”(Oxford English dictionary, 1999:30). In this study autonomy shall refer to opportunities created by an attending midwife during childbirth for a mother to give birth as she wish. Mothers displayed limited information with regard to available options during childbirth. According to the interviews there is less than adequate indication to midwives about their wishes.
However, one mother participant with twin
pregnancy was very happy because she gave birth as she wished; this was supported by her quotation from the interview: Miss B¹ “I had a twin pregnancy; I was very scared especially with malpresentation. I wished that I could deliver by caesarean section, indeed the doctors booked for the operation when they observed that my labour was progressing slowly.”
44
3.2.2.3 Theme C: Informed Choices/Lack of Making Informed Choices “Having sufficient information to enable the person to decide for him/herself” (Pera & Van Tonder, 1996:155). In this study informed choices shall refer to when accurate and up-to-date information has been provided to enhance such an informed choice. It was clear from the interviews that most mother participants did not have proper information with regard to childbirth issues and options. This may interfere with their capacity to make informed choices. The following excerpt from the interviews characterizes this statement: Miss I²,
“During childbirth I didn’t know that I can indicate any preference,
Miss J¹,
I just thought that I will do whatever midwives tell me to do. I was listening to all what the midwives were telling me to do. At times
Miss K¹ & Miss L¹
(laughing…) we don’t know that some of the things can be possible.”
Contrary to the above, mother participants made informed choices during childbirth as supported by the following quotation from the interviews: Miss G²,
“Hmm … With the information that I have, there is nothing that can be done to relieve pain during childbirth except the analgesics. So as I’m updated with the progress of labour I’m able to make informed choices like relaxation techniques.”
Miss H²;
Midwives should give me information, and then I would be able to
Miss J¹
make choices. They must listen to my request and if it is not approved they must explain that to me because they know. I got a thorough explanation from the midwife on what was going to happen during childbirth and I was able to cope with pain without a need for an injection because it is natural to feel childbirth pain.”
45
3.2.2.4 Theme D: Empowering/Powerlessness “To give power or authority to; to enable” (Oxford English Dictionary, 1999:164). In this study empowering shall refer to the process where the midwife work collaboratively with mother and will provide the mother with accurate information about childbirth issues and options, create opportunities for mother to participate, make decisions and take responsibility in own care. Some of he mother participants displayed powerlessness when they were supposed to communicate to midwives how they experience pain. When asked about how they express the feeling severe of pain in order to get the attention of the midwife, the following quotations from the interviews were cited: Miss B¹,
“Hmm … nothing, I would just keep quiet and wait for the
Miss H² &
midwife to come and examine me and then I would report to her that I’m feeling pain. Childbirth pain should be there,
Miss F¹
there is nothing that can be done to relieve it, only the delivering of the baby. Even in the Bible it was indicated that a woman would experience pain during childbirth, so the soothing/ encouraging phrases will suffice.”
46
3.2.3 CATEGORY 3: OPEN COMMUNICATION AND LISTENING
Table 3.5: Category 3: Open Communication and Listening THEMES A. Verbal/Hindered Verbal Communication B. Trust/Lack of Trusting Relationship C. Physical/Lack of Physical Comfort Measures and Emotional Support D. Authoritative Approach (Limited Human Rights)
3.2.3.1 Theme A: Verbal/Hindered Verbal Communication “Of or in words; spoken” (Oxford English Dictionary, 1999:577). In this study verbal communication shall refer to the transfer and understanding of a message between the midwife and the mother. When one party does not understand the language of the other a hindered verbal communication/ language barrier may develop Mother participants felt that the attending midwives lacked listening skills which hindered verbal communication during childbirth. Remarks made from the interviews were: Miss J²
“Some midwives must be patient and at least listen to what I want to say, they have knowledge and I know that they are busy but even if you ask a small thing they won’t listen. For example, if you indicate the preference they don’t allow or even listen to why you make such a preference.”
Language was also cited as a factor which interfered with the interaction of the mother and her attending midwife. The following citations by two mother participants who were not sharing the same language as that of the midwife supported this notion:
47
Miss B¹
“Hmm … I didn’t clearly understand the language of the midwife, but I would like to be assisted especially if there are complications. I would also be happy if the midwives can be more approachable, listen to what I say and not to be too harsh.”
Miss C¹
One mother participant who was a transfer from another hospital said, “ At my home hospital there was no problem because the sisters were understanding me when we communicate, but here I didn’t clearly understand their language so I was just keeping quiet during childbirth.”
3.2.3.2 Theme B: Trust/Lack of Trusting Relationship “To have firm belief in someone’s honesty or power” (Oxford English Dictionary, 1999:558). In this study a trust relationship shall refer to that which obtains when a mother believes that the attending midwife will provide her with assistance during childbirth. During the interviews this theme did not come out clearly from mother participants. Whether or not there was trust in the attending midwives, mothers nevertheless depended on them even if they referred to them as being unfriendly.
3.2.3.3 Theme C: Physical/Lack of Physical Comfort Measures and Emotional Support Mother participants had different opinions with regard to the physical comforting measures that were taken by the midwives when they experienced pain during childbirth. Excerpts from the interviews that indicated the provision of physical comforting measures and emotional support during childbirth were as follows: Miss E²
“The midwife was good to me, because she was assisting me to deal with my pain.”
Miss H²
“When I was experiencing severe pain, she told me to lie on the
48
side, sit or adopt any position that I feel comfortable. But it was the same and she reported to the doctor, the injection was given to me.” Miss F¹
“The midwife was very understanding, she was reassuring me with soothing phrases, since I knew that I’m going to experience severe pain, but I felt better under her care.”
Miss I¹
“I was very satisfied with my midwife’s care she was always with me and she was very knowledgeable.”
Contrary to the above, excerpts from the interviews that were in support of lack of physical comforting measures and emotional support were follows: Miss D¹,
“When I’m experiencing childbirth pain, midwives must empathize
Miss G¹ &
with me. I was feeling severe pain, calling with no response and I
Miss C²
nearly delivered the baby being alone without their assistance. I would call the midwife, but she would scold me saying I’m not cooperating and that didn’t I know that during childbirth it is normal to feel pain.”
3.2.3.4 Theme D: Authoritative Approach (Limited Human Rights) Mothers regarded the knowledge and experience of midwives as preeminent and unquestionable. This also became apparent under the theme of decision-making. The quotations from interviews that indicated an authoritative approach were: Miss B¹,
“Midwives have knowledge, I was doing all what they were telling
Miss C¹ &
me to do and when they told that I won’t deliver, an operation was
Miss K²
performed. I was told that it is the doctor who can decide whether I will undergo an operation or not. During childbirth I don’t have to indicate my preferences, but I must listen to all what midwives say. ”
49
3.2.4 CATEGORY 4: ACCOMMODATIVE/NON-ACCOMMODATIVE ACTIONS Table 3.6: Category 4: Accommodative/Non-Accommodative Actions THEMES A. Guide, Support and Respect of Choices B. Presence of Companion C. Conflicting of Expectations D. Unrealistic Choices
3.2.4.1 Theme A: Guide, Support and Respect of Choices Accommodative actions are defined as the assistive, supportive, facilitative or enabling creative midwifery actions and decisions that help a mother to adapt or negotiate with midwives for a satisfactory childbirth outcome (Leininger, 1991:48). In this study accommodative actions shall refer the midwife’s support, respect, promotion and encouragement of the mothers to indicate/ verbalize their preferences. Interview transcripts from mother participants it did not reveal whether they were getting guidance and support from their attending midwives. On closer observation of the results mothers indicated that they received limited guidance and support during childbirth. Regarding respect, only one mother participant responded as follows: Miss I¹
“During childbirth I expect midwives to be friendly and to respect me as an adult.”
3.2.4.2 Theme B: Presence of a Companion The opinions of the mothers on the presence of a companion during childbirth were variable. The majority of mother participants were in support of the presence of a companion, but indicated that they were not aware that this wish could be
50
accommodated. The following excerpts from the interviews characterize this sentiment: Miss D²
“Hmm … for the fact that my partner was not allowed in, I was afraid to be left alone.”
Miss C² &
“I wanted to be with someone during childbirth, even the presence
Miss D¹
of the midwife throughout labour because if she is present, she will communicate with me, give me information and this will assist me to feel less tense.”
Miss E¹
“If I knew that my partner could be allowed in, I would have loved that so that he can witness how the baby is delivered and I think this will strengthen the bond between the two of us.”
Miss F¹
“My partner should be present, he must see how pain is, and he must be involved and understand how painful childbirth is … and he will agree if I opt for sterilization.”
Miss H¹
“I think his presence will mean a lot to me and show love for his children.”
Contrary to those who considered the presence of a companion as desirable, other mothers preferred to be alone or only the presence of a midwife during childbirth. The following remarks from the interview transcripts substantiate this: Miss A² &
“(Laughing) … my husband … he is nervous, he is afraid
Miss L²
(laughing), but I didn’t know that such a wish could be allowed during childbirth.”
Miss I²
“Yes its OK, to have a companion, but I prefer to be alone and I want to be respected.”
51
Miss I¹
“I would prefer to be with my mother-in-law and not my husband, childbirth is a woman s’ business.”
Miss C¹
“I only prefer to be alone with the midwife, no member from my family ‘ba tlo mponela’. I want to be alone I want my space.”
3.2.4.3 Theme C: Conflicting Expectations In this study conflicting expectations will be viewed as situations where there are no expectations or clarifications (lack of contract). It was evident from interview transcripts of mother participants that on admission in the labour ward clarification on expectations were not made, hence leading to conflicts. The following quotations from the interview transcripts support this view: Miss D¹
“When midwives scold me, I become anxious and fear to verbalise any wish that I’m having.”
Miss C²
“I expected good care from the midwives. They must treat me as a person, listen to me and empathise with me as I was feeling pain.”
Miss F¹
“I was experiencing severe pain and an urge to bear down, but they were expecting me to be up and about as they were saying that I would deliver quickly.”
Miss G¹
“During childbirth there should be communication between the midwife and myself, they must listen and clearly explain to me if what I prefer is not possible. In my case I felt less pain when squatting, but I was told to adopt lateral position before delivery and dorsal position during delivery.”
52
3.2.4.4 Theme D: Unrealistic Choices During the childbirth process the midwives assess mothers and ensure that both the lives of mother and baby are not in danger. One mother participant had choices that may put the life of the baby in danger; hence the mother felt that her wish was no accommodated. The following excerpts from Miss G² interviews characterized this statement: Miss G²
“I didn’t want to be cut (episiotomy) during childbirth, because I felt that my baby’s head was small, but the midwife would not listen to me, she was scolding me and telling me that I’m still a child (18 years) to have a baby.”
3.2.5
CATEGORY 5: MAXIMIZE INFRASTRUCTURE
HUMAN
AND
MATERIAL
Table 3.7: Category 5: Maximize Human and Material Infrastructure THEMES A. Shortage of Staff B.
Labour Ward Infrastructure
3.2.5.1 Theme A: Shortage of Staff In this study, shortage of staff is defined as less than adequate number of available staff to provide quality midwifery care during childbirth. In the interview transcripts of mother participants, it was noted that one midwife had to care for more than one mother at the same time. Remarks from mother transcripts in support of this the statements were:
53
Miss A¹,
“I couldn’t communicate freely with the midwife because she was
Miss J¹ &
very busy, but she was examining me when I reported/ requested help. The midwife was busy with other mothers; she was not in my
Miss D¹
cubicle throughout the childbirth.”
3.2.5.2 Theme B: Labour Ward Infrastructure One mother participant indicated that she preferred to be with her partner during childbirth, but her wish was not accepted because of the labour ward infrastructure. The following excerpt from the interviews confirmed this: Miss D¹
“I requested to have my partner with me during childbirth, but the midwife explained to me that it would not be possible to have my partner in my cubicle because there are other mothers who are in the labour ward, my partner will see those mothers ‘o tlo ba bonela’.”
3.3
RESULTS OF THE OBSERVATIONS ON ACTIVITIES AND INTERACTION DURING CHILDBIRTH
The participant observational guide and visual analog scale were used to obtain information on communication, informational support, emotional support activities, supportive care activities and physical comforting measures that takes place during childbirth. Observations were done during the active phase of labour (cervical dilatation of 3 cm) until the end of the third stage of labour. The results from the observations were categorized as follows: • Communication between mothers and attending midwives during childbirth • Informational support during childbirth • Emotional support activities during childbirth • Supportive care activities during childbirth • Physical comforting measures rendered when mothers experienced pain
54
The results are presented in graphs as follows: 3.3.1 Communication Between Mothers and Attending Midwives During Childbirth Communication between the mothers and attending midwives during labour was determined by observing the following interactions and activities: • Ability of Midwife to Empower the Mother • Enabling the Mother to Feel Special and Relaxing • Determining the Mother’s Cultural and Personal Preferences • Continuous Updating on Foetal and Maternal Progress • Advocacy Skill Analysis of this sub-category indicated that the communication between the mother and the midwife occurred more when the midwife was rendering the midwifery care and very limited during affective communication. This was evidenced by (10) 83% of midwives when continuously updating the mother on maternal labour progress and on foetal well-being. Limited affective communication was displayed which is thought to facilitate mutual participation as evidenced by (3) 25% of midwives advocating mothers when with the doctor, (2) 17% of midwives were able to empower mothers, (3) 25% of midwives were enabling the mother to feel special and relaxed and (1) 8% of midwives determined the mother’s cultural/personal preferences.
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Percentage Interaction
100 75 50 25 0 M idw ife able to em pow er m other during labo ur En able the m other to feel s pec ial and relaxed Be a m other's advoc ate w hen w ith the doc tor D eterm ine m other's c u ltural preferenc es C ontinuous up date on m aternal and foetal progres s
Fig ure 3 .1 : Interaction/communica tion betw een mothers and attending midw ives.
Table 3.1 indicates that from the total population of mothers (n=24) recruited in the study, 7 (29%) were not sharing the same language with the attending midwives. Hindered verbal communication as a result of language barriers and non-listening skills were displayed during the interaction of a midwife and a mother during childbirth in this study. Persson and Dykes (2001:56) firmly supposed that the experience of good care appeared to be dependent on communication and behaviour to be able to meet mothers just as they are.
3.3.2 Informational Support During Childbirth From the profile of mothers recruited to the study (Table 3.1), 23 (96%) did not participated in childbirth preparation classes. Only 1 (4%) mother participated in childbirth classes, hence it can be inferred that mothers probably had limited information support from the attending midwives during childbirth. To determine
56
whether informational support was given by the attending midwives to mothers during childbirth, the following were observed: • Answering of mother’s questions • Allowing/encouraging mothers to ask questions • Advising mothers on the physiological changes of labour • Offering mothers opportunities to come up with suggestions • Extending advice and encouragement • Guiding and assisting mothers throughout delivery
Analysis of the observations in this category (Figure 3.2) revealed that during information sharing between the mother and the midwife more emphasis was placed on the assistive actions than on the activities that would promote mothers’ participation. It was noted that (9) 75% of midwives were advising mothers on changes taking place during childbirth and guiding and assisting them throughout childbirth. Actions that were promoting mothers’ participation were limited as only (4) 33% of midwives extended encouragements, (1) 8% offer opportunities for mother to give suggestions whilst (1) 8% of attending midwives allowed mothers to ask questions which were answered during childbirth.
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Percentage Informational Support
100 80 60 40 20 0 Midw ife answ ers all mother's questions Midw ife allow s mother to ask questions Midw ife advises mother on labour c hanges Midw ife offers opportunities for mother to make suggestions Midw ife gives advic e and enc ouragement Midw ife guides and assists mother throughout delivery
Figure 3.2: Informational support and exchange between mothers and attending midwives.
3.3.3 Emotional Support During Childbirth To determine the emotional support given by the attending midwives to mothers during childbirth the following were observed:
• Instilling of confidence and encouragement of the companion’s presence • Be understanding, friendly and reassuring • Encouraging free choice and full participation • Fostering the integration of cultural/personal preferences • Showing of respect
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Analysis of this sub-category indicated that attending midwives offered limited emotional support during childbirth as evidenced by the observation that (0) none of the attending midwife encouraged the presence of a companion and integration of cultural/ personal preferences during childbirth. Only (4) 33% of attending midwives showed respect to mothers during labour whereas (3) 25% were encouraging free choice and full participation of the mothers. A significant number of attending midwives (8) 67% displayed an understanding, friendly and reassuring attitude to mothers during childbirth. Figure 3.3 illustrates that only (4) 33% of midwives showed respect to mothers. Rice (1999:246) indicated that lack of respect and disregard of the choices for mothers, in the mothers’ narratives, contribute to apathy towards respect in their treatment and inability to exercise choices in decision-making. Respect empowers women (Gibbins & Thomson, 2001:310). Results also indicated that none of attending midwives were instilling confidence or encouraged the presence of a companion during childbirth. In an incident during the study, one midwife participant was very much stressed and insensitive with an instructive attitude. She was also impatient to an extent that little or no explanations were give during the provision of care. Hence, the mother participant was absolutely terrified as no comforting words were forthcoming from the midwife participant. This resulted in mother not co-operating as there was no gestures of understanding between the two.
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Percentage Emotional Support
100 80 60 40 20 0 M idw ife ins tills c onfidenc e, enc ourage pres enc e of c om panion M idw ife is unders tanding, friendly and reas s uring M idw ife enc ourages free c hoic e and full partic ipation M idw ife s how s res pec t M idw ife fos tering the intergration of c ultural preferenc es
Fig ure 3 .3 Emotional support activities by attending midw ives during childbirth.
3.3.4 Physical Comforting Measures When Mothers Are Responding To Pain The visual analog scale (VAS, 100mm tool) was issued to mothers and their attending midwives with the aim of comparing the pain experienced among mothers during childbirth and to observe the awareness and responses of the attending midwives to the pain exhibited by mothers. Mothers and their attending midwives had to complete the scale independently during the following phases of cervical dilatation: • 0-3 cm, mothers were experiencing moderate pain while attending midwives perceived as mild pain • 4-7 cm, mothers experienced severe pain while midwives still perceiving as mild pain • 8 – 10 cm, both groups experienced and perceived painas severe.
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All assessments were completed independently and without reference to the previous rating. Findings refer to Figure 3.4.
The analysis of findings on VAS indicated that mothers were experiencing severe pain throughout labour (with a pain score 6-8), while the pain midwives exhibited (perceived) was mild-moderate at the beginning of labour (2.5 – 4.5) but at the end of labour pain score was similar to that of mothers (9.5). On observation of the midwives’ responses to the mothers’ pain were similar throughout the childbirth process. Support given by the attending midwives to the mothers when experiencing
10
Analog Scale)
Average Pain Level (Visual
pain is displayed in Figure 3.5.
8 6 4 2 0 0-3 cm
4-7 cm C e rv ic a l D ila t a t io n
M o th e r s
8-10 cm
M id w iv e s
F i g u r e 3 . 4 : P a in s c o r e s b y v is u a l a n a lo g u e s c a le .
3.3.5 Supportive Care Activities During Childbirth When the mother was responding to childbirth, the following supportive care activities were determined: • Provision of Physical Care • Attendance to the Elimination Needs • Midwife Caring for More than One Mother at the Same Time
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Figure 3.5 presents the findings on supportive care activities by midwives when mothers were experiencing childbirth. 100% of the midwives provided care for mothers’ elimination needs. Midwives could not give individual care to mothers, as they were caring for more than one mother at the same time. There was a shortage of staff as (3) 25% of midwives were caring for more than one mother. Only (1) 8% of midwives provided physical care during childbirth (physical care include touching, rubbing/ massaging). Very few mothers were given analgesics as
Percentage Support Care Activities
prescribed.
100 80 60 40 20 0
P r o v is io n o f p h y s ic al c ar e E lim in atio n n eed s C ar in g f o r m o r e th an o n e m o th er at a tim e
F ig u re 3 .5 S upportive c a re a c tivitie s by a tte nding m idw ive s during c hildbirth.
3.4
SUMMARY
The research findings of the mothers’ experiences were discussed in this chapter. It is evident that mothers’ needs/ wishes/ preferences should be determined in order to provide ‘woman-centered care’ in the childbirth units of Mankweng Hospital in Capricorn district of the Limpopo Province. The next chapter deals with the results of the experiences of the attending midwives on the management of mothers during childbirth.
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CHAPTER 4 DISCUSSION OF RESEARCH FINDINGS: EXPERIENCES OF ATTENDING MIDWIVES ON MANAGING MOTHERS DURING CHILDBIRTH
4.1
INTRODUCTION
In this study the focus will be on discussing the results of interviews conducted with attending midwives regarding their experiences of managing mothers during childbirth at Mankweng Hospital in the Limpopo Province (Attending Midwife’s Transcript, Addendum 4). Data collection was carried out through the fieldwork at Mankweng Hospital’s obstetrics unit in the Limpopo Province. Data was collected until saturation was achieved. The target population was all attending midwives with at least 2 years experience and who provided midwifery care to mothers during childbirth in the tertiary hospital. Two years experience was considered to be a sufficient period of midwifery exposure of managing mothers during childbirth.
A criterion for
selection was described in Chapter 2. Sampling was purposive and consisted of 12 attending midwives (Table 4.1). The data collection method consisted of a semi-structured interview that was based on one central question: “Could you please tell me your experiences of managing mothers during childbirth?” Probing as a communication strategy was used to obtain more data from attending midwives. The other data collection methods utilized included a semi-structured observation guide and the visual analog scale. These were described in detail in Chapter 3.
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Table 4.1: Profile of the Attending Midwives Recruited to the Study (n=12) Characteristic 1.
2.
3.
No 0
Gender Male Female
12
Qualification Registered Midwife Advanced Nurse Midwife Duration of Allocation in the Labour Ward 2-4 5-6 >7
10 2
6 4 2
4.
5.
Ethnic group Northern Sotho Tsonga Venda Tswana Other Religious Affiliation Lutheran Apostolic Church Zion Christian Church (ZCC) Other (Specify)
9 2 0 1
4 2 2 4
4.2
DISCUSSION OF RESULTS: ATTENDING MIDWIVES
Like the findings of mothers, the results from the experiences of midwives on managing mothers during childbirth revealed five (5) major categories (Table 4.2). 1.
Mutual Participation and Responsibility Sharing
2.
Information Sharing and Empowering
3.
Open Communication and Listening
4.
Accommodative/Non-Accommodative
5.
Maximizing of Human and Material Infrastructure
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The identified categories will be discussed below:
4.2.1 CATEGORY 1. MUTUAL PARTICIPATION AND RESPONSIBILITY SHARING In this category, five themes were identified as presented in the Table 4.3. Each theme will be discussed separately. Table 4.3: Category 1: Mutual Participation and Responsibility Sharing THEMES A. Participation/Lack of Participation B. Responsibility/Lack of Responsibility in Own Care C. Dependency D. Decision Making/Lack of Decision Making E. Facilitation/Promotion of Participation
4.2.1.1 Theme A: Participation/Lack of Participation According to attending midwives, the mother’s participation in her childbirth could be strengthened when a therapeutic environment is created. One midwife participant exemplified this by describing how she supported the mother by explaining all procedures to her and facilitated/ promoted her participation by indicating that she must come up with her preferences for childbirth, and encouraging her to ask questions. Miss C, D,
Midwife participants pointed out that “although mothers did not
Miss E, H,
indicate their behaviour as preferences, they nevertheless participated by adopting a squatting position during childbirth.”
Miss G & Miss I
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Table 4.2: Categories and Themes 1.
2.
3.
4.
5.
Mutual participation and
Information
Open
Accommodative/non-
Maximize
responsibility sharing
sharing and
communication and
accommodative
human and
empowering
listening
midwifery actions
material infrastructure
A.
Participation/ lack of
A.
participation
Limited
A.
Verbal/hindered
A.
Guide, support
information
verbal
and respect
about
communication
choices
A.
Shortage of staff
childbirth issues and available childbirth options B.
Responsibility/lack of
B.
responsibility sharing
Autonomy/lack
B.
of autonomy
Trust/lack of
B.
trust
Presence of a companion
relationship C.
Dependency
C.
Informed
C.
choices
Physical/lack of
C.
physical
Conflicting expectations
comfort measures and emotional support D.
Decision making/lack of decision making
D.
Empowering/ powerlessness
D.
Authoritative approach (limited human rights
E.
Facilitation/promotion of participation
D.
Unrealistic choices
B.
Labour ward infrastructure
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Other midwife participants were of the opinion that mothers do not participate at all in their care during childbirth. The following supporting quotations from the interviews were cited: Miss C
“The mother may not, however, be willing to participate in her care for various reasons; the mother maybe unprepared for her childbirth or maybe mother had not discussed participation during pregnancy.”
Miss E
“You know some mothers are from the cultural system where the mother is not used to express her wishes as this is not allowed, for example, if the partner is available during childbirth, when asked her wishes, she will look at the partner and expect him to decide.”
Miss H,
“Mothers don’t indicate their preferences or wishes during
Miss D,
childbirth; they just listen to what we are telling them to do as midwives.”
Miss L & Miss J
4.2.1.2 Theme B: Responsibility/Lack of Responsibility in Own Care According to attending midwives, the responsibility of mothers during childbirth is to co-operate and communicate to the midwives their feelings, thoughts and preferences. Miss E indicated that mothers should co-operate throughout the childbirth process; they must communicate their needs because where possible, their needs are considered, ‘because we have to make decisions together’. Midwives were of the opinion that mothers are not taking responsibility in own care when they are: • Pushing before the cervix is fully dilated • Closing the thighs instead of adopting a lithotomy position
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• Not listening and following all the instructions of midwives
The following quotes were cited by the midwives:
Miss C
“Mothers very easily put themselves into the hands of the midwives. I don’t know what’s the cause or is it because there were no discussions regarding responsibility during pregnancy? But at times there is an attitude in our society that say a pregnant mother is ill and must leave all the responsibility to the midwives because they know best.”
4.2.1.3 Theme C: Dependency The midwife participants were of the opinion that lack of participation and responsibility sharing by mothers during childbirth promotes dependency on midwives. Miss E
“Mothers put themselves in the hands of midwives because they say we know best and they don’t know.”
Miss F
“(Quiet) … Hmm … Yes … to a lesser extent, mothers usually listen to what the midwife or doctor say, they don’t object.”
4.2.1.4 Theme D: Decision Making/Lack of Decision-Making The task of midwives is to support mothers in their decisions. In this study this was a problem because mothers did not express of any explicit decision. The following excerpt from the interview characterizes this statement: Miss A
“I encourage involvement and decision making, but mothers would say help/assist me because you are an expert. Anything that you do or say is OK as long as I deliver a healthy baby.”
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Hence Miss I indicated that, “Mothers are allowed less or minimal decision-making because a midwife is trained for what she is doing, so the mother must listen to the midwife.” Miss C indicated that “I don’t think there will be a problem in allowing and encouraging mothers to be involved in decision-making, but they don’t usually indicate that they want to take part or decide in their care. They follow what the entire midwife or the doctor say.”
In the provision of midwifery care, midwives are more likely to adopt authoritarian and decisive attitudes, especially if complications have occurred.
Miss F supported the above notion by stating that “(Laughing) … Hmm …I think mothers should participate and take decisions in their care during childbirth by choosing what they want, but when there are complications the doctor or the midwife should decide on the management.”
4.2.1.5 Theme E: Involvement
Facilitation/Promotion
of
Participation
and
The midwives could support and give the mother an opportunity to participate and be responsible during childbirth by being open, listen to mothers, explain all procedures, show respect, and clarify each other’s expectations through provision of information on childbirth issues and available options. This support will facilitate an environment conducive to mothers to become more involved and participate willingly in their midwifery care.
The following excerpt from the interviews characterizes this statement: Miss B
“Yes, I do, by friendly welcoming a mother and explaining all procedures to be done on her I think I’m promoting her to
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come-up with her preferences. Mothers are also allowed to give feedback of the care received and clarifications are given to them.”
4.2.2 CATEGORY 2: INFORMATION SHARING AND EMPOWERING
TABLE 4.4 CATEGORY 2: INFORMATION SHARING AND EMPOWERING THEMES A. Limited Information About Childbirth Issues and Available Childbirth Choices B. Autonomy/Lack of Autonomy C. Informed Choices D. Empowering/Powerlessness
4.2.2.1 Theme A: Limited Information about Childbirth Issues and Available Childbirth Choices Most midwife participants were of the opinion that mothers displayed lack of information/knowledge, understanding and awareness on what should obtain during childbirth. The following were cited: Miss A
“Most mothers look confused and don’t listen to the instructions carefully, they are anxious and don’t co-operate.”
Miss D
“Mothers seemed to be lacking information; some will even refuse to be done vaginal examination.
Miss G
“Primigravidae are worse because they close the thighs when the head crowns, but those with little information on what is going to happen, they are better, they do co-operate.”
Miss B
“Mothers must utilize the health education as this was given at the Antenatal clinic on what to expect during labour.”
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Miss K
“Some mothers do lack information/ knowledge or they even had misconception and they resist changing, for example, if the mother indicates the preference of normal vaginal delivery and this was clearly indicated to her that this is ‘trial’, if normal vaginal delivery fails, the mother would resist changing inspite of the explanation given. Mothers are not aware that the course of childbirth can sometimes be unpredictable and result in change of preferences.”
4.2.2.2 Theme B: Autonomy/Lack of Autonomy Most midwife participants felt that opportunities were created during childbirth for mothers to give birth as they wish. The following quotations support the idea, promotion of autonomy: Miss H
“Yes mothers are given the opportunities to give birth as they wish …, most mothers are delivered in dorsal position which is routinely used but if the second stage is prolonged the mother would say ‘ nurse I think if I can squat the baby will come out’ and that is considered.”
Miss I
“Very few mothers will tell the attending midwife that the baby will never come out until the drip is inserted or perhaps given enema before delivery. It will be explained to the mother that intravenous infusion is only inserted if there are indications like foetal /maternal distress and not on maternal request.”
Miss K
“Some mothers do request caesarean section for delivery, but in this institution an indication should be valid and assessments or investigations should have been done, this is explained to the mother.”
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On the other hand, some midwife participants did not promote autonomy, as supported by following statement: Miss I
“Mothers prefer squatting position especially the grandmultiparae, in the hospital it becomes difficult to manage delivery and to maintain sterility.”
4.2.2.3 Theme C: Informed Choices/Lack of Making Informed Choices During the childbirth process it was evident that mothers with accurate and up-todate information with regard to childbirth issues and the available options were able to make informed choices. The following excerpt from the interviews exemplifies this statement: Miss E
“Mothers who do not have accurate information don’t have specific choices/ wishes during childbirth and they are unco-operative as compared with those with accurate information, and they display informed refusal of treatment. She further elaborated by stating that, “You know, what I observed is that most mothers do attend antenatal care clinics, but childbirth preparation classes are not conducted or provided. (This was also detected from the demographic data of mothers, Table 3.1 because if the childbirth preparation classes were provided the information given would enhance the mothers’ sense of confidence by having accurate and realistic information which will enable them to make informed choices and feel in control of their childbirth process.”)
4.2.2.4 Theme D: Empowering/Powerlessness When limited opportunities are created to empower mothers during childbirth, they are rendered powerless as evidenced by dependency as already discussed.
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The following quotations from the interviews support the above statement:
Miss F
“Maybe the mothers’ limited exposure to information make them to accept childbirth pain as a normal process, as such they don’t verbalize any wish or suggestion during childbirth.”
Miss C
“I don’t think mothers have to choose during childbirth, but they follow what the midwife say/ expect from her.”
4.2.3 CATEGORY 3: OPEN COMMUNICATION AND LISTENING
Table 4.5: Category 3: Open Communication and Listening THEMES A. Verbal/Hindered Verbal Communication B. Trust/Lack of Trust Relationship C. Physical/Lack of Physical Comfort Measures and Emotional Support D. Authoritative Approach (Limited Human Rights)
4.2.3.1 Theme A: Verbal/Hindered Verbal Communication Midwife participants were of the opinion that mothers are made to feel free to verbalize their thoughts and wishes during childbirth. Midwives indicated that they are being open, support and listen to mothers to understand their unique circumstances and their wishes. The following citations showed that language barriers often are the major causal factors that interfere with midwifery care provision. Miss B
“Some mothers are difficult and are unable to follow instructions especially if they don’t understand the language.”
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To care for a mother who does not speak the same language as the midwife, presents obstacles as one midwife participant stated: Miss D
“Midwife’s physical presence helps to establish some contact with the mother if the midwife and mother are not sharing the same language.”
4.2.3.2 Theme B: Trust/Lack of Trust Relationship Midwife participants thought that they were displaying a form of trust relationship when they were firm and honest to mother. Honesty strengthens the self-confidence of mothers. The citations in support of this statement were: Miss B
“I think it is important for us midwives to make it clear to mothers under our care, for example, by indicating that’ it is important for me that you have a good childbirth, I’m available for you, I care for you, but you are not the only patient for me, you are my patient right now.”
4.2.3.3 Theme C: Physical/Lack of Physical Comfort Measures and Emotional Support Midwife participants generally held the view that they are providing emotional support when they involve and explain all the procedures to the mother during childbirth. The following quotation supports the above statement: Miss B
“I think it is important for us midwives to make it clear to mothers under our care, for example, by indicating that’ it is important for me that you have a good childbirth, I’m available for you, I care for you, but you are not the only patient for me, you are my patient right now.”
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Miss H
“To show that I care I will up-date her about the progress and indicate that I understand that it hurts to give birth, this shows that I’m concerned.”
Miss J
“I become friendly and welcome mothers in the ward; I explain to them all the procedures and encourage them to come up with their preferences.”
Miss L
“I allow mothers to give feedback on the midwifery care they receive and I give clarifications on their concerns.”
During childbirth mothers would experience severe pain. They would scream and state that childbirth pain is unbearable. The midwife’s task would be to be sensitive to and to follow the mother through the phases of childbirth, taking into consideration her capacity to deal with pain. The following citation supports the view that comforting measures were lacking during childbirth: Miss G
“Mothers are very unco-operative, especially during the second stage of labour, for example, the primigravidae are worse because they close the thighs when the head crowns.”
4.2.3.4 Theme D: Authoritarian Approach (Limited Human Rights) It was evident from the interviews that mothers unquestioningly accept decisions made by midwives without them uttering a word. Midwives place themselves in the position of authority that allows them to tell mothers what to do and deprive them of control over their wishes during childbirth. This was confirmed in an interview with one midwife participant: Miss K
“Mothers are allowed less or minimal decision making because a midwife is trained for what she is saying and doing, so the mother must listen.”
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Almost all midwife participants during the interviews, when asked about the mothers’ involvement/ participation during childbirth, expressed phrases like “I allow the mothers to, expect her to listen, expect her to follow instructions as I tell her … , ” which indicated the authoritative approach. There was no room for negotiation with mothers due to a top-down approach by attending midwives (Miss A, Miss B, Miss C, Miss D, Miss F and Miss I).
4.2.4 CATEGORY 4: ACCOMMODATIVE/NON-ACCOMMODATIVE MIDWIFERY ACTIONS Table 4.6: Category 4: Accommodative/Non-Accommodative Midwifery Actions THEMES A. Guide, Support and Respect of Choices B. Presence of Companion C. Conflicting of Expectations D. Unrealistic Choices
4.2.4.1 Theme A: Guide, Support, Respect and Promotion of Preferences Midwife participants asserted that they support, promote and respect the values, beliefs and preferences of mothers as long as these are not harmful. In support of this assertion, one midwife participant stated:
Miss I
“I accommodate mothers’ preferences, for example, squatting, but if I find difficulties in managing childbirth, I explain to the mother the benefits of adopting dorsal position and guide her in adopting the position”
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4.2.4.2 Theme B: Presence of a Companion In studies conducted on the presence of and support from mothers’ companions, it was found that this preference is seen as important in helping the mother to feel confident during childbirth. In this study the midwife participants raised variable opinions on this issue which also differed to those of mothers. The responses from midwife participants who supported the presence of a companion were as follows:
Miss F
“If the couple/mother verbalizes the wish to be with the companion during childbirth, yes, I do allow that.”
Miss G
“I allow the presence and support of the partner during delivery because if the companion is present during childbirth s/he will support by soothing massage to the mother.”
To other midwife participants the presence of a companion was viewed as an interference with their contact relationship with the mother. Quotations in support of this statement: Miss J
“The presence of a companion/ partner during childbirth is an obstacle to good relationship, it is very difficult to establish contact with the mother in the presence of the father who at times displays negative attitude, worried or who is aggressive.”
Miss E
“The presence of the partner interferes with the mother’s decision, especially in cultures where husbands are the decision makers. In one incidence, when the mother was asked about her wishes, she will look at the husband and ask him to decide. This made me to feel that I can’t do anything about that.”
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4.2.4.3 Theme C: Conflicting Expectations From the interview excerpts midwife participants were of the opinion that mothers are expected to cooperate during childbirth. According to them, mothers were not complying with their expectations during childbirth, hence there were conflicts and mothers were viewed as being uncooperative. Quotations were: Miss L
“Mothers are not cooperative, they are expected to know what needs to be done to them like, per vaginal examination, not to push before the cervix is fully dilated, to open their legs during delivery and they are expected to listen and follow the midwives’ instructions.”
Miss F
“Grand multipara mothers prefer to deliver in the squatting position, which makes it difficult to manage complicated delivery and to maintain sterility during childbirth.”
4.2.4.4 Theme D: Unrealistic Choices Several midwife participants indicated that some mothers were participating during childbirth, but their preferences/wishes were not accommodated by midwives because these were not realistic. One midwife participant stated that: Miss D
“Culturally, mothers would choose to deliver on the floor; on a squatting position (laughing …) it was difficult to accommodate this wish … not on the floor.”
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4.2.5 CATEGORY 5: MAXIMIZE INFRASTRUCTURE
HUMAN AND MATERIAL
Table 4.7: Category 5: Maximizing of Human and Material Infrastracture THEMES A. Shortage of Staff B.
Labour Ward Infrastructure
4.2.5.1 Theme A: Shortage of Staff Midwife participants were of the opinion that to provide quality midwifery care, continuous presence, provision of hands on comfort and encouragement by midwives should be provided. In this study there was a shortage of staff in the labour ward hence midwives could not provide such quality care. Quotations indicating the shortage of staff were: Miss H
“We have to care for more and more mothers at the same time and we often think that time for the individual mother is lacking.”
Miss K
“We usually make it clear to mothers under our care that ‘you are not the only patient for me.”
4.2.5.2 Theme B: Labour Ward Infrastructure One midwife participant was of the opinion that the structure of the labour ward was not conducive for her to allow the presence of the partner during childbirth. The following excerpts from the interviews characterize this statement: “When we allow a partner in the ward at times is embarrassing because the structure is not en-suite type, privacy is not sufficient because other labouring mothers will be screaming with midwives giving instructions; there is a lot of noise.”
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4.3
SUMMARY
In this chapter the research findings of attending midwives were discussed. The experiences during the management of mothers during childbirth revealed that there is a need for mutual participation and responsibility sharing, information sharing and empowering, listening to mothers, clarifications of expectations on admission and accommodating mothers preferences. According to the midwife participants’ transcripts, physical comforting and accommodative measures were sought for and applied in order to support, guide and respect mothers’ preferences during childbirth. From the discussions in this chapter, it is evident that mothers’ needs/wishes/preferences should be determined in order to provide woman-centred care during childbirth.
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CHAPTER 5 COMBINATION OF THE RESULTS OF MOTHERS AND ATTENDING MIDWIVES AND LITERATURE CONTROL
5.1
INTRODUCTION
In the previous chapter the focus was on the results of the interviews conducted with attending midwives regarding their experiences of managing mothers during childbirth. This chapter focuses on combining the results of mothers’ childbirth experiences (Chapter 3) and attending midwives’ experiences of managing mothers during childbirth (chapter 4). Discussion and clustering of the results from empirical data according to identified relationships will be made. The results will be presented in two sections. The first section will comprise statements that are related to the categories and these will be underlined. In the second, section the discussion will be realized against the background of the literature control. According to Cresswell (1991:23), the literature control is presented at the end of the study for it to become a basis for comparing and contrasting the findings of the qualitative study.
5.2
COMBINATIONS AND DISCUSSION OF SIMILARITIES AND DIFFERENCES
The discussions of both Chapters 3 and 4 revealed differences and similarities in the mothers’ and attending midwives’ experiences, with regard to mutual participation and
responsibility
sharing,
information
sharing
and
empowering,
open
communication and listening and accommodative/ non-accommodative midwifery actions this hospital of the Capricorn district in the Limpopo Province.
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5.2.1
Section One: Presentation of Data
5.2.1.1 Mutual Participation, Responsibility Sharing, Dependency and Decision-Making The transcripts of both mothers’ and attending midwifes participants indicated that there is limited participation and collaboration between them childbirth. The midwife participants indicated that mothers don’t participate in their care; the contributory causes might be lack of participation in childbirth classes or the sociocultural system. It was indicated that mothers don’t indicate/ verbalize their preferences on arrival. An observation showed that there was no record that indicated whether the preferences were verified or not by the midwives. It was also affirmed that mothers just listen to attending midwives. On the other hand, mothers were of the opinion that midwives do not involve them when providing midwifery care as they will just instruct them on what to do and midwives are not friendly. With reference to responsibility sharing and decision-making, the midwives’ transcripts indicated that mothers displayed limited responsibility sharing during childbirth. Two attending midwives indicated that mothers easily put themselves in the hands of midwives, which might be due to socio-cultural beliefs that pregnancy is an illness, this was viewed by midwives as ‘dependency syndrome’. Midwives also indicated that mothers don’t cooperate during childbirth. However, throughout the study it was observed that limited room was afforded for mothers to negotiate with midwives. Midwives had authority over mothers and frequently used the following word: I expect her to listen, expect her to follow the instructions as I tell and allow the mother to … hence mothers were dependent on midwives with restricted interdependence. Mothers, on the other hand, were comfortable with their dependency on the midwives as they indicated that midwives are trained practitioners and they know
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best. Mothers articulated that they don’t have anything to say, but to listen to the midwives. Since mothers depended on midwives, it was evident that they had limited decision-making capability. Midwives were of the opinion that during childbirth mothers were not verbalizing that they would like to make decision; they would follow all that the midwives instruct them to do. By contrast, one mother participant indicated that she was willing to take part in decision-making, but lacked factual/ accurate information with regard to the available options.
5.2.1.2 Information Sharing, Empowering and Autonomy When information is shared with regard to childbirth issues and available childbirth options outlined, the mothers would be empowered. Midwife participants pronounced that mothers lack information/knowledge, understanding and awareness on what should happen during childbirth. The above statement was also reflected in the mothers’ transcripts. Mothers emphasized that they were lacking factual information on childbirth issues and on available birth options/choices. With regard to autonomy, midwife participants insisted that they do create opportunities for mothers to give birth as they wish, especially when the wishes/preferences are not conflicting/interfering with midwifery care. On the other hand mothers pointed out that they lacked autonomy, which might still be due to limited information. It was evident from the interview transcripts of both midwives and mothers that limited information with regard to childbirth issues, available childbirth options and understanding of what should happen during childbirth, do contribute to limited capacity of making informed choices by mothers during childbirth. Again it was determined that when limited opportunities are created to empower mothers (to provide information) during childbirth; mothers become powerless as evidenced by inadequate participation, lack of responsibility sharing, restricted decision-making capacity, dependency on midwives and limited capacity of making informed choices.
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5.2.1.3 Open Communication and Listening, Trust Relationship, Physical Comfort and Emotional Support Communication between a mother and a midwife during childbirth should be open, effective and both parties should understand the language of one another. From the interview transcripts of both midwives and mothers, language barriers were cited as a factor that interferes with their interaction during childbirth (especially to mothers who were transferred from other hospitals and who use a different language from that of the midwife) because in this hospital provides midwifery care for all racial groups. It was cited from mother participants that midwives were impatient, do not listen and seldom verify why they are having specific preferences. With regard to trust relationship during midwifery care, one midwife participant indicated that she becomes firm and honest to mothers in order to build the trust relationship. Nothing was indicated by mother participants with regard to trust relationship. Concerning physical comfort and emotional support, the experience of childbirth pain by mothers was said to be unbearable. Mothers had different opinions with regard to the care received from midwives. Some mother participants indicated that midwives were knowledgeable, understanding, reassuring and with soothing phrases the care was good. On the other hand, some mother participants had a firm conviction that midwives lacked comforting measures and emotional support skills. They indicated that midwives had no empathy, I nearly delivered alone without assistance. Some midwives would scold and utter phrases like “didn’t you know that in childbirth it is normal to feel pain?”
5.2.1.4 Accommodative Midwifery Actions, Presence of Companion Pertaining to the issues of being accommodative, midwife participants deemed that they promote, support and respect the values, beliefs and preferences of mothers as long as they are not harmful to the mother and baby. They were also convinced that some mother participants had unrealistic choices, which were not accommodated by
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midwives in their care. Contrary to this, mothers responded to midwives that they want to be respected and treated as adults. Presence of a companion: midwife participants were in support of the presence of a companion during childbirth, but raised concerns like: presence of companion interferes with their interactive relationship with the mother, especially when the partner is aggressive, it interferes with the mothers’ decision-making capacity and ward structures are not conducive to allow the presence of a companion. Mothers indicated that they would prefer the presence of a companion, but were not informed that this was possible. Statements like, I wanted my partner to witness how our baby is delivered, to bond so that my husband understands when I opt for sterilization, were noted.
5.2.1.5 Shortage of Staff and Ward Structures Shortage of staff was cited in interview transcripts of both mothers and midwives. It was pointed out that one midwife would be caring for more than two mothers at the same time. Midwives were not able to spent quality time with the mothers, and to verify their preferences.
5.2.1.6 Facilitation/Promotion of Participation With regard to facilitation/promotion of participation, very few midwife participants indicated that they support and give the mothers opportunities to participate and be responsible during childbirth, by being open, listening, explaining all procedures, showing respect, clarifying each other’s expectations and provision of information on childbirth issues and available options. By so doing, they were of the opinion that they genuinely facilitate an environment for mothers to become involve and participate in their midwifery care. These concur with the opinion of almost all the mothers during childbirth as they valued the presence of a midwife to give detailed information on what to expect and about the progress of labour. Mother participants thought this would enhance their participation and allay their anxiety.
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A friendly attitude, being approachable, demonstrating patience, not to scold and have respect was also mentioned as a strategy that would allow mothers not to be afraid to voice their preferences. Mothers were of the opinion that midwives should ask them what they want and not to always tell, tell, tell. Mothers acknowledge that midwives are trained as professionals. Mothers also indicated that midwives should allow them to take decisions especially if their decisions are not interfering with midwifery care, like allowing partners in the ward if they prefer to be with them during childbirth. Mothers had expectations that midwives must listen and empathize with them when they feel pain, and treat them, as they (midwives) would like to be treated and give them advice. Mothers further indicated that clarification of expectations from both parties on admission would facilitate open communication during childbirth. To accomplish the assistive, supportive, facilitative and enabling midwifery actions that will assist mothers to adapt to midwives for a satisfactory childbirth outcome, expectation clarifications/contract in the form of ‘woman-centered birth-plan’ should be sought with the mother before childbirth.
5.2.2 CLUSTERING OF CATEGORIES ACCORDING TO THEIR RELATIONS During discussion, comparison and combination of concepts, the results of the interviews seemed to have revealed a midwife-centred care (Figure 5.1) rather than women-centred care (Figure 5.2) during childbirth within the childbirth unit of this hospital in the Capricorn district of the Limpopo Province. Accordingly, the focus of this study would propose to move from ‘midwifery-centered care to womancentered care.’
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5.2.2.1 Midwife-Centered Care Midwife
Mother 5 Mother 1 Mother 4 Mother 2 Mother 3
Figure 5.1: Midwife-Centered Care
In midwife-centered care, it is the midwife who tells mothers what to do and how to behave. This approach during childbirth is characterized by: • Limited mutual participation and responsibility sharing, which comprise of inadequate participation, limited decision-making scope and a proliferation of practices that foster dependency, and a prevailing authoritative approach within the childbirth unit. The strict routines that are laid down by the regulations seem to depersonalize the mother, resulting in non-participation. Midwives impose their authority and responsibility to ensure that rules are adhered to. Mothers are merely seen as the ones who should comply with the rules of the unit with no power of decision, and there is over-reliance on technology. • Limited information sharing and empowering is displayed in this approach, that is, information regarding childbirth issues and awareness of available options are not shared with mothers which result in powerlessness and lack of autonomy in childbirth care.
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• Hindered/ineffective communication, for example, inadequate listening skills by attending midwives and the existence of a language barrier between mothers and midwives often result in limited participation. The midwifecentered care approach seemed to limit itself to the physiological processes and the psychosocial aspects of the mother is thus ignored. • Non-accommodative midwifery actions with regard to poorly defined perceptions of conflicting expectations and unrealistic choices of the mother were manifested. In the midwife-centered care, the management of childbirth is focused on detection of complications, which does not always respect the experience and expectations of childbirth and its outcome.
5.2.2.2 Woman-Centered Care
Midwife
Mother 1
Mother 5
Mother 2
Mother 4 Mother 3
Figure 5.2: Woman-Centered Care
The woman-centred care approach during childbirth is characterized by: • Participation that requires a mutual, egalitarian and respectful relationship. Equality includes the principle of sharing power and responsibility. There should be leverage for negotiation between the mother and the midwife.
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• Sufficient information provided by the attending midwives and which is a prerequisite for decision-making. • Interaction between the mother and a midwife should enhance the selfesteem and self-determination of the mother. The midwife and the mother should listen to each other because they engage in a dialogue to identify preferences and expectations and a new strategy for change is constructed. • In this study the new strategy for change will be to develop woman-centered childbirth model and criteria that would be integrated within the Batho-Pele Principles aimed at enhancing the facilitation of mutual participation during childbirth.
During the clustering, comparison and combination of concepts, the results of interviews revealed the dependency on midwifery-centered care rather than interdependence/woman-centered care in the tertiary hospital of the Capricorn district o the Limpopo Province. The woman-centered care was found to be a core category for this study.
Groups of experiences (clusters) that were classified as practices that foster/promote dependency in midwifery care are as follows (Table 5.1): • Lack of mutual participation and responsibility sharing (mother participation and midwife collaborative actions) • Limited information sharing and empowering actions between midwife and mother during childbirth • Ineffective verbal communication and inadequate physical comforting measures during childbirth • Non-accommodative midwifery actions • Limited human and material infrastructure within the childbirth units of the tertiary hospital in the Capricorn district, Limpopo Province
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5.3
Section Two: Literature Control
Factors that promote midwife-centered care (Table 5.1) will be utilized as a basis for the discussion against the literature control as follows:
5.3.1 Limited Mutual Participation and Responsibility Sharing From the results of this study, mothers displayed limited participation and responsibility sharing with midwives during childbirth. There was no evidence or record showing that the mothers’ preferences were verified and discussed with the mother on arrival in the ward. There was limited mother-midwife collaboration as was indicated by mothers that midwives do not involve them when providing care, but midwives will instruct mothers what to do. According to Berg et al. (1996:15), mothers are said to have had negative experiences when they lost control of the situation and not having been able to participate in decision-making. They further indicated that this occurred in situations where midwives took control without giving the mother time to be involved. In the context of this study, mothers were accepting (without questioning) decisions made by the midwives. This stance would place a midwife in a position of power and authority to make decisions. During other instances the mother did not always understand why certain decisions were made, but she would still comply because of the trust she put in the decision maker regardless of what the decision entailed. Bluff and Holloway (1994:160) pointed out that women placed themselves in the hands of midwives and allow midwives to make decisions for them even if their own wishes were neglected. However, Nolan (1997:1201) was of the persuasion that the provision of information is making a significant contribution towards putting most mothers at the centre of their own care and enabling them to participate in decisions during childbirth.
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Table 5.1: Experiences that Were Classified as Practices that Foster/Promote Dependency on Midwifery Care 1. Lack of Mutual Participation and
3.
2.
Ineffective Verbal/
Limited Information Sharing and Empowering
Responsibility Sharing
Communication and
4.
5.
Non-Accommodative
Limited Human and Material
Midwifery Actions
Infrastructure
Inadequate Physical Comforting Measures
Related attributes in statements:
Related attributes in statements:
-
Limited mother
-
participation and midwife collaborative actions -
Related attributes in statements: -
Hindered
-
Respect–promote:
-
Shortage of staff –
communication
respect values, beliefs
caring for more than
information/
language barrier, use
and preferences if not
two mothers at the
knowledge and
of different language
harmful (by
same time
understanding/
which interferes with
midwives). Contrary,
Limited participation in
awareness on
interactive
mothers want to be
childbirth classes due to
childbirth issues
relationship
respected and to
-
Related attributes in statements:
Limited
socio-cultural system -
Related attributes in statements:
Limited factual
-
Midwives are
Mothers just listen to
information on
impatient and not
midwives
available birth
listening or verifying
options
why a mother has a specific need
-
Midwife not spending quality time with mother
betreated as adults -
Ward structure – not conducive to allow the presence of a companion during childbirth
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Table 5.1: Experiences that Were Classified as Practices that Foster/Promote Dependency on Midwifery Care (Continued) 1. Lack of Mutual Participation and Responsibility Sharing
2.
3. Ineffective Verbal
Limited Information
4.
5.
Non-Accommodative Midwifery
Limited Human and
Actions
Material Infrastructure
Communication and
Sharing and Empowering
Inadequate Physical Comforting Measures -
Not involved, just instructed
-
Limited responsibility sharing
-
Mothers do not verbalize
-
Informed choices –
-
-
Mothers easily put themselves in the hands of midwives, limited interdependence
-
Limited (no) presence of
limited capacity of
emotional comfort
companion, although
making informed
measures – variable
midwives indicate,
choices
responses: midwives
supporting on the other
knowledgeable,
hand, presence interfere
understanding,
with interaction relationship
preferences -
Limited physical and
Limited opportunities created for mothers to
reassuring with soothing
make choices as
words
evidenced by limited: participation,
-
-
Mother’s decision capacity. Mothers would appreciate
Un-approachable (cold
the presence of companion
responsibility sharing,
midwives) lack
but were not informed
decision-making
cordiality or emotional
capacity and
warm – midwives lack
powerlessness
comforting measures and emotional support.
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Table 5.1: Experiences that Were Classified as Practices that Foster/Promote Dependency on Midwifery Care 1. Lack of Mutual Participation and Responsibility Sharing
2.
3. Ineffective Verbal
Limited Information Sharing and Empowering
Communication and
4.
5.
Non-Accommodative
Limited Human and
Midwifery Actions
Material Infrastructure
Inadequate Physical Comforting Measures -
Dependency on midwives
-
Limited decision making
-
capacity and autonomy -
-
-
No empathy,
-
Poorly defined
scolding, I nearly
conflicting
delivered without the
expectations/ needs
midwife’s assistance,
and unrealistic choices
Limited room for mothers
utter phrases like –
are not accommodated
to negotiate with
didn’t you know that
midwives
childbirth is painful?
Midwives had authority
-
-Trust relationship –
over mothers (expect,
Midwives were firm
allow)
and honest to build
Midwives are trained
trust relationship
practitioners – they know best
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Nolan further indicated that the midwives are challenged to enforce equal opportunities of making information available and to encourage mothers to take responsibility for their own care. Ritcher, Greaney, Roberts et al. (2001:174) further supported this contention by indicating that participative decision making requires that patients are knowledgeable about their health care, that is, they have the ability to process medical information and can understand the outcomes of choices they make. Lack of participation may frustrate patient satisfaction with the outcomes. Gibbins and Thomson (2001:310) indicated that being included in and making decisions were reported as crucial in helping mothers feel in control. Lundgren and Dahlberg (2002:158) pointed out that it is important for midwives to collaborate by inviting the mothers to participate and be responsible for their care during childbirth. Although they clarified that limited participation and responsibility sharing could be interfered with as a result of unpreparedness for childbirth, or due to ignorance obliviousness of taking responsibility for their own situation. To midwives in this study, this was referred to as socio-cultural vulnerability of the mother. According to the ‘Pregnant Patients’ Rights’ in Ladewig et al. (1998:795), the patient has the right to be informed by the attending midwife about the available childbirth education classes, which could help to prepare the mother physically and emotionally to cope with the stress and experience of childbirth and to participate actively during childbirth. However, in the study “Woman’s Perceptions Of Informed Choices In Maternity Care” by O’Cathain et al. (2002:143), it was suggested that women who were multiparous and of lower educational status preferred not to participate in decision making with midwives, but further indicated that it is important for midwives at least to know how women in their care prefer to be involved in decision as an aim to be sensitive and flexible in meeting women’s needs. According to Halliday and Horgarth-Scott (2000:52), childbirth is a natural process and mothers should be at the center of decisions about their care. However, Pelkonen et al. (1998:22) pointed out that it was obvious that not all clients were willing to participate.
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Health professionals especially doctors, have become experts on childbirth and their decisions are considered preeminent over those of mothers. Their authoritative approach focuses only on the signs and symptoms of the mother. Women feel that when decision about their childbirth is made they do not have any choice; they are either not informed about birth procedures or are coerced to follow their caregivers’ instructions (Rice, 1999:247). In one incident in this study, the mother lacked autonomy because the episiotomy was performed during childbirth without her consent and knowledge. Moore (2000:26) observed that the principle of autonomy asserts both the right and the responsibility of a competent individual (mother) to make decisions whether or not to choose options that are consistent with beliefs and values. Fu-Chang Tsai (2002:45) supported this notion when stating that health professionals must have respect for autonomy. Patients who are competent to make decisions should have a right to do so, and midwives should have a concomitant duty to respect their preferences regarding their own care. In a woman-centered care the midwife takes the following into consideration” kindness and respect, a listening-care, a share in decision-making, a chance for a mother to talk about her care, this approach would facilitate participation during childbirth.
5.3.2 Limited Information Sharing and Empowering Actions Lack of shared information was seen as an obvious concern. Halliday and HogartScott (2000:63) along with Gibbins and Thomson (2001:302) stated that there were many expressions of needs for information, reassurance and confidence building. In addition, Ritcher et al. (2001:174) pointed out that if women are not given adequate information, they may not be able to collaborate with their physicians or be willing or able to ask questions. Sharing of information in advance could build the necessary trust so that goals could be consciously adapted throughout the childbirth process. Limited information, ideas and options are often cited as reasons why women are socialized to accept pain as woman’s “lot” (WHO, 1998).
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Research has shown that gaining accurate and reliable information about childbirth during pregnancy can influence the degree of confidence a mother has in her ability to cope during childbirth (Gibbins &Thomson, 2001:310). In analyzing the mothers’ and midwives’ transcripts, it became evident that mothers possess limited information with regard to the childbirth issues and the available childbirth options. To correct the situation, Gibbins and Thomson (2001:302) suggested that information given during childbirth enables the mother to take decisions and empowers her to make informed choices. This idea was supported by Nolan (1997:1201) that woman need to be given information and opportunity to discuss how that information relates to their particular circumstances, and further indicated that information builds confidence and self-esteem so as to enable the mother to take control over her childbirth, ask questions, make informed choices and communicate more effectively with midwives. By contrast, Bluff & Holloway (1994:161) indicated that (whether or not the mother posses information,) was the midwife’s perspective and mothers are unaware of this apparent lack of knowledge. However, it is documented that lack of accurate/factual information contributes to mothers’ limited capacity of making informed choices, lack of autonomy and power. There is a wide consensus on the importance of sufficient information as a prerequisite for decision-making. Information should be provided on the different options available for and their consequences in an individual, understandable and non-controversial manner (Pelkonen, Perälä & Vehviläinen-Julknen, 1998:22; Gibbins & Thomson, 2001:310). According to Levy (1999:110) women require information during pregnancy and delivery (childbirth) to guide their actions and to raise their awareness of issues to be considered and options open to them. In the study on Midwife/Client Relationship: Midwife’s Perspective, McCrea and Crute (1991) found that some mothers were not listening to the midwives, but they looked to doctors for information. When focusing on the regulation of information, mothers tend to avoid receiving information if they regard it as irrelevant to their situation, but women-centred care may make the difference, because the mother
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and a midwife engage in a dialogue to identify preferences and expectations. Levy (1999:112) noted that some mothers would delay pursuing information as they felt the time was not right for the topic to be addressed. Midwives have the capability of assisting mothers to contextualize the information, by the creation of a trust relationship through respect. However, Pope et al. (2001:238) pointed out that some indication of stereotyped views were apparent. If the mother is respected she will personalize this information, value it and apply it for change (empowered) especially through the women-centered care approach. During actioning mothers would be empowered and feel confident that they understand the issues involved and could make a choice on their care. Strategies to facilitate communication and implementing choices to show that a mother is empowered were outlined by Levy (1999:115) as follows: • Asserting, mothers will openly express their choices with confidence. • Playing the game, mothers will not allow the attending midwife to impose their choices, but will openly participate in decisions.
5.3.3 Ineffective Communication Lack of effective communication between a mother and a midwife may perhaps lead to failure of clear explanation about the childbirth process from the midwife. Language difficulties and lack of information and clarification on the part of midwives also contribute to misunderstanding and miscommunication (Rice, 1999:242; Ito & Sharts-Hopko, 2002:673). Rice (1999:242) affirmed by indicating that due to lack of English communication with caregivers, women felt that they did not have any great concern about it, and further indicated that woman did not understand the midwife and could not ask any questions during childbirth. Listening to the woman include a shift of focus in childbirth, from the midwives themselves to the mothers. Mothers’ needs and desires should be the focus and not those of the midwives (Lundgren & Dahlberg, 2001:157). Limited listening skills
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lead to ineffective communication. The midwife should display openness, which is a mark of a true willingness to listen, see and understand. In some instances mothers felt that some procedures were imposed on them. This observation was corroborated by Viisainen (2001) who reported that, the way in which interventions and processes were introduced was in an authoritative or non-listening manner and this made mothers to feel disturbed. On the other hand, midwives also did show concern for the mother as was discussed by McCrea & Crute (1991) in the study Midwife/Client Relationship: Midwives Perspectives. They observed that mothers do not listen to midwives, and this led to the feeling of worthlessness, the midwife will just go through the process of helping the mother but no mutual trusting relationship is established. Windridge and Berryman (1999:22) specified another factor that was raised by the mothers which interfered with communication, namely,
midwives were
unapproachable, cold and unfriendly. Hence, midwives should be regarded as a friend
who
is
warm,
caring/empowering
and
professional
rather
than
uncaring/discouraging (Lundgren & Dahlberg, 2001:155). According to Tarkka, Paunonen and Laippala (1999:188) for the attending midwives to influence mothers positive childbirth experiences, they should display empathy, friendliness, tenderness, calmness, alertness, peacefulness and professional expertise. Mearns and Thorne (1998) cited in McCrea & Crute (1991:190) stated that midwives are socialized to be “professional” and would clearly have difficulty in empathizing with mothers. Yet empathetic understanding of clients’ concerns is considered a vital component for a mutual trusting relationship to move towards therapeutic ends. Takayama and Yamazaki (2003) recognized a need for effective patient-physician communication in childbirth, which was referred as mutual participation and consultation. The study group conducting the review in (Brown & Lumley, 1998:107) outlined the potential benefits of birth plan (woman-centered care) with regard to communication as:
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• Improved channels of communication between the caregivers and the consumers. • Creation of opportunities for discussion of preferences. To the researcher, these benefits would enhance effective communication during childbirth.
A trusting relationship will be established if a friendly and gentle environment is created. This will then lead to openness and conveyance of safety. According to Berg, Lundgren, Harmansson & Wahlberg (1995:13), a trusting relationship develops, and this mediates a feeling of tranquility and security and the woman could relax and feel that she is participating in decision-making and thus gain some control measure of situation. Thus, emotional aspect of the mother becomes supported.
5.3.4 Limited Physical Comforting Measures Mothers and midwives raised different opinions with regard to physical comfort during childbirth. According to Bluff & Holloway (1994:160) it was stated that mothers regarded midwives as practitioners of normal midwifery and “they know best”. Some mothers experienced limited physical comforting measures during childbirth. The following physical comforting measures (Department of Health (2001); Tumblin & Simkin (2001:54); Simkin (1995:170); Simkin (1996) could be preferred by the family during childbirth and can be achieved through womancentred care: • Encourage the presence of companion • Hand, foot and back massage • Cold packs, hot packs, warm blanket or cool cloth to brow • Reassuring touch (holding, patting hand, stroking cheek) • Suggestions for different positions for delivery • Shower or tub • Double hip squeeze, counter pressure, knee pressure
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• Encouragement of mobility during labour.
The woman-centred care encourages mother’s ideas and view the mother and midwife as partners because it takes the mother’s emotional and social environment into account (Anderson, 2002:80; Johnson, 2003:30).
5.3.5
Non- Accommodative Midwifery Actions
5.3.5.1 Respect Mothers valued to be respected by the midwives during childbirth. Some mothers felt respected if midwives considered their preferences or explained reasons for not considering preferences. Pope et al. (2001) were of the opinion that if a womancentered birth plan were to be used women’s choices would be facilitated and they would feel respected. To other mothers, an indication of lack of respect by midwives was an issue that interfered with decision-making. Women valued to be treated as individuals as opposed to an object in the system. A recent study of “Women’s Experiences with the Encounter with the Midwife During Childbirth,” reaffirmed that women need to be viewed as individuals, have a trusting relationship and be supported and guided on their own terms (Berg et al., 1996: 12; Tinkler & Quinney, 1998:34). However, Machin and Scamell (1997:84) noted out that mothers are vulnerable during childbirth, they are often not capable of choices, and they are reassured by the safe boundaries set by medicalization. The provision of woman-centered care would thus empower the mother.
5.3.5.2 Limited/Minimal Presence of a Companion Mothers and attending midwives had variable preferences and views regarding the presence of a partner during childbirth. Several authors have spelt out clearly the advantages of the presence of a companion during childbirth (Micklethwait, Beard & Shaw (1978:190); Somers-Smith (1999:105). In this study, some mothers felt that
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their partners should witness the childbirth for them to understand the childbirth process and to develop a bond with their babies. However, Lundgren & Dahlberg (2002:158) stated that some midwives indicated that the presence of the father interfered with their contact relationship with the mother. In support of this, Nolan (1997:1198) concluded that in most parts of the world childbirth is a woman’s issue and in the vast majority of traditional cultures it is unheard of for men to be present at birth.
5.3.5.3 Expectations In this study some conflicting expectations were evident between the mother and a midwife during childbirth. Nolan (1997:1201) suggested that women need to be given information and opportunity to discuss how that information relates to their particular circumstances before the stresses of labour make it unrealistic to enter into detailed considerations of the pros and cons of childbirth. However, Shorten et al. (2002:19) indicated that mothers’ choices could be an important determinant, but it is the responsibility of the midwife to inform the mother about her choices. Moore and Hopper (1995:29) have shown that the use of birth plans limits conflicting expectations, since women indicated that birth plans enabled them to express their needs, preferences and enhanced their confidence and further improved communication between them and their attending midwives.
5.3.6 Limited Human and Economic Infrastructure In this study both the attending midwives and mothers cited shortage of staff as a problem that was interfering with the provision of quality midwifery care during childbirth. Research confirmed that shortage of staff interfered with the provision of care. Lundgren & Dahlberg (2001:158) observed that midwives in maternity care had to care for more and more women at the same time and often time for an individual
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woman was lacking. Fleissig (1993:73) noted that mothers displayed lack of information due to staff shortage. Pelkonen et al. (1998:22) stated that a busy and routinized atmosphere has been found to inhibit participation, whereas a friendly peaceful and secure situation provided opportunities for participation. Staff shortages do contribute to a feeling of tension in clinics and on the wards (Micklethwait et al, 1978:190). Simkin (1995:170) was of the opinion that if one-to one nursing care not possible (except in high risk situation), physical comforting measures can be taught by midwives to the mother’s partner. The situation would be different when a woman-centered care birth plan is used, as was determined by Whitford et al. (1998:249) Mothers who were looked after by more than one midwife found such care beneficial because it helped them to get what they wanted and it acted as an aid to communication between the two.
5.4
SUMMARY
In this chapter, differences and similarities of the results of field research have been discussed and clustered according to the identified relationship. The clusters have been realized against the background of the literature control. To counter-act factors that contribute to limited mutual participation and responsibility sharing, womancentred care has been identified as a central approach to enhance mutual participation and responsibility sharing. For this study woman-centered care seems to be the best approach with the characteristics that would promote mutual participation. In the next Chapter 6, woman-centered childbirth model and criteria would be developed.
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CHAPTER 6 A WOMAN-CENTERED CARE: CONCEPT ANALYSIS
6.1
INTRODUCTION
Analysis of data from mothers’ and the attending midwives’ transcripts in Chapters 3 and 4 led to the synthesis and identification of the core category as womancentered care (Table 5.1). In this chapter, concept analysis of woman-centered care will be conducted in order to analyze and generate descriptions, definitions and to further explore the meaning of this concept in childbirth. The results from analysis together with the findings summarized in Table 5.1 will facilitate the development of a model for womancentered childbirth and formulation of criteria for woman-centered care.
6.2
CONCEPT ANALYSIS
Concept analysis utilizes the framework described by Walker and Avant (1995): • Select a concept • Aims of analysis • Identify uses, characteristics or connotations of the concept • Determine defining attributes • Develop the model cases • Identify antecedents and consequences • Define empirical referents
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6.2.1 Select a Concept The theoretical stage begins with the selection of the concept. The woman-centered care was selected as a core concept in this study because it was found to be the central idea or event and all the other categories are related to it. This was described in detail in Chapters 3, 4 and 5.
6.2.2 Aims of Analysis The aim of the analysis will offer a vehicle for identifying the shared meaning of concepts which is imaginative. The objective of concept analysis is to identify the characteristics or connotations of the concept (Rossouw, 2000:103). Kay (1999) stated that concept analysis is not just concerned with discovering definitions and meanings, but also explain why those meanings have developed. Moreover, concept analysis is also used to define a term for subsequent research or to examine how a concept is used within the current literature or in actual clinical practice (Chinn and Kramer, 1995:81).
6.2.3 Identify Uses, Characteristics or Connotations of the Concept To accomplish the identification of the uses, characteristics or connotations of the concept, the dictionary, impression of colleagues and available literature on the subject will be examined. Dictionary definitions are authentic because they convey accepted ways in which words are used. This in turn can be useful in defining the scope of any subsequent analysis of the literature. The woman is part of the family and the concept of woman-centered care is ill-defined in dictionaries, however Mosby’s Medical and Nursing Dictionary (1983:414) was used to define the use of family-centered care (woman- centered care). The definition suggests that family centered care (woman centered care) is a holistic approach, with professionals and family working collaboratively towards a common outcome. The opportunity is thus given to the family members to care for their relative (during childbirth). The collaboration allows independence and co-opt the family in the plan of care.
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Family-centered care is firmly entrenched in respect for and cooperation with the family. According to this view, the nurse is an equal partner and a facilitator of care. Empowerment of women during childbirth is possible but may need to be conceptualized differently from the family-centered care. Proposed here is a woman-centered care that shift the emphasis back onto the mother as a key principal in childbirth and grants her the mandate to personalize her birth to suit both her needs and the needs of her family. In childbirth, for example, the concept womancentered care is used in relation to mutual participation and interdependent collaboration. According to Kay (1999) the focus of the literature gathered is on identifying the essential nature or ‘essence’ of the concept in the form of attributes. The attributes are not dictionary definitions, but represent the ‘real definition of the concept’. Woman-centered care as a core concept refers to involving the woman in treatment decisions, increasing communication between the midwife and woman towards an understanding of what to expect from treatment plans, recovery and after care (Bechell, 2000:402). Johnson, Stewart et al. (2003:30) referred to woman-centered care as a process in which a woman is making choices, being involved in and having control over her care and relationship with her attending midwife. Likewise, woman-centered care encourages the mother’s ideas, views the mother and the attending midwife as partners, takes the mother’s emotional and social environment into account and requires mutual participation (Anderson, 2002:80). Womancentered care, according to Rush (1997:1), refers to a complex, multidimensional, dynamic process of providing safe, skilled and individualized care. It responds to the physical, emotional and psychosocial needs of the mother. However, woman-centered care as outlined within the context of the Batho-Pele Principles in the White Paper on Transforming Public Service Delivery (1997) is a customer-oriented care, namely, a midwife consuls a mother, encourage her involvement and support her choices about services offered. A mother is allowed to practice preferences (courtesy), equal access to personal control and decision making (access). Moreover, a mother is given full and accurate information about
105
childbirth and midwifery care to which she is entitled. Turkel (1990:65) referred to women-centered care as the sum of activities that include emotional involvement, responsible participation and a sharing of practical and technical knowledge of health care.
6.2.3.1 Connotations of Woman Centered Care that Emerged from the Literature
In this study woman-centered care is seen as a philosophy of care that brings about the mutual participation and involvement of both the mother and the attending midwife. However, Nethercott (1993) cited in Kay (1999) identified the differences between a mother’s involvement and participation. It was indicated that involvement is seen as a precursor of woman-centered care where the attending midwife would exercise control over the mother’s involvement, whereas a mother’s participation was supposed to be based on a more collaborative relationship and partnership. Participation in this study is exhibited by open communication, mother’s involvement in decision-making, consultation and collaboration between a mother and the attending midwife. There is respect and the midwife listens to the mother’s views. There is also exchange of complete and unbiased information, recognition and honoring of the cultural diversity and making of informed choices. However, such list of connotation does not clarify the concept. Rossouw (2000:104) stated that analysis involve analyzing the component of the whole and sort them into categories to make the concept more understandable.
6.2.4 Determine Defining Attributes Walker and Avant (1995:41) described defining attributes as the characteristics of the concept that appear over and over again. Utilizing the definition of woman centered care as given above, essential attributes are: mutual participation and responsibility sharing, information sharing and empowering, interdependence and
106
collaboration, participative decision-making, open communication and listening, respect and accommodative midwifery actions, self-determination and self- reliance and maximizing of human and material infrastructure. The interaction is dependent upon mutual participation, interdependent and collaborative actions of both the mother and the attending midwife during childbirth. Analysis of the literature presented the following connotations ascribed to woman-centered care during childbirth.
Mutual Participation and Responsibility Sharing
Collaboration and Interdependence
Information Sharing and Empowering
Woman-Centered Care
Open communication and listening
Accommodative
Maximize Human and
Midwifery Actions
Material Infrastructure
Figure 6.1: Theoretical Framework of Defining Attributes of Woman- Centered Care
The illustration the relationships among specific mutual participation and collaboration between mothers and the attending midwives during childbirth are depicted in Figure 6.1. Woman-centered care will be assessed in its optimal sense for the purposes of critical attributes formation, model case development and the determination of antecedents and consequences. Therefore, the essential attributes of woman-centered care during childbirth as determined from the data are as follows:
107
• Mutual
participation
and
responsibility
sharing
as
evidenced
by
interdependent collaboration, co-operation and consultation between the mother and the attending midwife during childbirth • Information sharing and empowering by virtue of exchange of complete and unbiased information that facilitate participation in informed decision making, informed choices and promote mother’s functioning and autonomy. • Communication and listening by means of a relationship that is nonjudgmental and that is based on honest and open communication, respect and listening to the mother’s views. • Accommodative midwifery actions through recognition and honoring of cultural sensitivity and support of choices. • Maximized human and material resources as borne out by adequate, competent staff to render midwifery care and provisions of privacy and presence of a companion during childbirth.
These critical attributes provide a more comprehensive view of woman centered care during childbirth. The focus of these attributes is on the positive aspect of woman-centered care during childbirth. The existence of these attributes reinforces woman-centered care during childbirth.
6.2.5 Develop the Model Cases A model case is a ‘real-life’ example of concept usage in which all the critical attributes are present (Walker & Avant, 1995:42). It is generally regarded that the author should be able to construct a model case which allows him/her to state ‘If this is not X, then nothing is’. In this context, the interviews with the mothers served as real-life cases because they indicated what mothers’ needs are with regard to
108
woman-centered care. The characteristics of woman-centered care were compared to critical attributes as follows: Comparison of the critical attributes and characteristics of woman-centered care (Table 6.1) revealed similarities. This was further supported by the literature (Section 6.2.3).
TABLE 6.1: Comparison of Critical Attributes and Characteristics of WomanCentered Care Critical Attributes (Section 6.2.4 and
Characteristics of Woman-Centered Care
Figure 6.2) Mutual participation and responsibility
•
Collaboration
sharing as evidenced by interdependent
•
Consultation
collaboration, co-operation and consultation
•
Involvement (control)
between the mother and the attending
•
Mutual participation
midwife during childbirth.
•
View mothers and midwives as partners
•
Interdependence
•
Provision of information in a friendly manner.
relationship that is non-judgmental and that
•
Respect (listening)
is
•
Encourages mothers’ views
•
Takes mothers’ emotional, social and cultural
Information
sharing
and
empowering
through exchange of complete and unbiased information that facilitate participation in informed
decision
making,
informed
choices and promote mother’s functioning and autonomy. Communication and listening by means of
based
on
honest
and
open
communication, respect and listening to mother’s views.
Accommodative midwifery actions through recognition
and
honoring
of
cultural
environment into account
sensitivity and support of choices. Maximized human and material resources borne out by adequate, competent staff to render midwifery care and provision for privacy and presence of a companion during childbirth.
•
Service to be responsive to the needs of mothers (support of choices)
109
6.2.6 Identify Antecedents and Consequences Walker and Avant (1995:45) define antecedents as events or incidents that must happen prior to the occurrence of the concept. Likewise, consequences are circumstances resulting from the occurrence of the concept (Walker & Avant, 1995:45). Examination of the antecedents and consequences of the woman-centered care allows further refinement of the critical attributes, thus facilitating the formulation of the criteria for woman-centered care.
6.2.6.1 Antecedents Antecedents of efficient woman-centered care as determined from this analysis are based on mutual participation and collaboration, open communication and listening, respect and honoring cultural sensitivity and information sharing which will lead to informed decision-making, choices and autonomy. There should be adequate and competent staff to provide midwifery care during childbirth. These are necessary conditions that must be satisfied before woman-centered care can be accomplished during childbirth. Richter et al. (2001:174) were of the view point that participative decision-making requires patients to be knowledgeable about their health care and that they have the ability to process medical information and understand the outcomes of the choices they make. If any of these conditions are not met, significant alterations in the mother’s – midwife’s mutual participation and collaboration might occur, thus interfering with the provision of woman-centered care. Since woman-centered care is viewed as a part of a reciprocal process, it is essential that a consistent attending midwife be present who is sensitive to the mother’s needs. Furthermore, if there is limited participation and collaboration, then lack of participation and informed decision-making will result from the mother. This may indicate the inability to meet the needs of the mother on the part of the midwife. Lack of participation may also decrease patient satisfaction with the outcome (Richter et al., 2001:174).
110
6.2.6.2 Consequences Some of the consequences of woman-centered care are highlighted as the critical attributes of the concept and these were corroborated by Pelkonen et al. (1998:22). They are as follows: • Mutual participation, egalitarian and respectful relationship • Equality with principle of power and responsibility sharing • Partnership and collaboration in decision making • Being well-informed that enhances self-esteem and self-determination • Interdependence If efficient woman-centered care occurs, mutual participation would automatically be obvious and mothers will participate in their care.
6.2.7 Define Empirical Referents Empirical referents are defined as classes or categories of actual phenomena that by existence or presence demonstrate the occurrence of the concept itself (Walker & Avant, 1995:46). The categories relate to critical attributes of the concept and in some cases the empirical referents are the same as the critical attributes identified. The empirical referents of woman-centered care in this study are: • Mutual participation and responsibility sharing • Information sharing and empowering • Communication and listening • Accommodative midwifery actions • Maximize human and material infrastructure
Each of these referents will be integrated within the Batho-Pele Principles and measured by the formulated criteria (Table 6.2). The construction of referents operationalises the concept of interest. Walker and Avant (1995:46) stated that referents, once identified, are extremely useful in instrument development because
111
they are clearly linked to the theoretical base of concept thus contributing to both the content and construction of the instrument and they will provide clear observable phenomena of the concept. Furthermore, instrument development in itself is an operational definition (Burns and Groove, 2001:147). From the results of concept analysis in this study the researcher will formulate the criteria for womancentered care that are integrated into Batho-Pele Principles in order to measure these empirical referents.
6.3
COMPONENTS OF THE THEORY
The development of the woman-centered care childbirth model will contain the following six components, namely, goals, concepts, definitions, relationships, structure and assumptions as outlined in Chinn and Jacobs (1987: 116).
6.3.1 Goals The main aim of developing the woman-centered childbirth model is to improve midwifery care through enhancing the implementation of the Batho-Pele Principles in the childbirth units in Capricorn district, Limpopo Province. The objectives of the model will be to: • Facilitate mutual participation, respectful and egalitarian relationship between the mother and the attending midwife during childbirth • Enhance equality that embraces the principle of power sharing and responsibility • Strengthen partnership and collaboration in decision-making • Enhance self-esteem, self-determination and self-reliance when the mother is well informed. • Promote interdependence
112
6.3.2 Concepts From the analysis of data, woman-centered care was identified as a major category. The process of concept analysis was conducted in order to identify the characteristics of the concept woman-centered care.
6.3.3 Definitions Definition of the concept woman-centered care was illustrated in detail (Section 6.2.3).
6.3.4 Relationships Relationship will be achieved by designing of relational statements by means of synthesizing the existing definition. According to Walker and Avant (1995: 55), synthesis is the process and strategy that provides a mechanism for creating something new from the data that are already available. From the existing definition, the researcher will synthesize a definition for woman-centered care within the context of this study. The process of synthesis as described by Walker and Avant (1995:100) will be adapted for this study (Chapter 2). The researcher has to develop statements that propose specific relationships among the concepts being studied. Knowledge for use in statement synthesis may be acquired through clinical observation and integrative literature review. Figure 6.2 provides an overview of the statements that are related to woman-centered care by examining the link between antecedents, defining attributes and consequences.
6.3.5
Structure
6.3.5.1 Conceptual Model Once synthesis has been completed, the conceptual model will be developed by utilizing the Dickoff, James and Wiedenbach’s (1968:423) survey list cited in Madela-Mntla (1999:69) and Tlakula (1999:119). The list include: Agent, recipient,
113
procedure, context dynamics and terminus/ goal. The utilization of the Dickoff, James and Wiedenbach’s survey list in a conceptual model is shown in Table 6.2. • • • • • •
Interdependent collaboration Participative decision making Promote functioning, informed choices and autonomy Open communication and respect Recognizing and honoring cultural sensitivity (accommodative) Adequate, competent staff and provision of privacy and companion ANTECENDENTS
• • • • •
Mutual participation and responsibility sharing Information sharing and empowering Open communication and listening Accommodative midwifery actions Maximize human and material infrastructure
DEFINING ATTRIBUTES
• • • • •
Mutual participation and egalitarian relationship Equality with principle of power and responsibility sharing Partnership and collaboration in decision making Well-informed to enhance self-esteem, self-reliant and self-determination Independence CONSEQUENCES
Figure 6.2: Synthesis of Relational Statements
114
Table 6.2: Conceptual Model Recipient: Mother
A person identified by virtue of her undergoing the childbirth process. The mother has been found to be dependent on the attending midwife as was evidenced by her limited participation and responsibility sharing during childbirth. Through the interaction that facilitates mutual participation, responsibility sharing, collaboration and sharing of information, the mother would participate in her care.
Agent: Attending Midwife
The attending midwife is a professional with specific skills who interacts with the mother to promote mutual participation and share information to facilitate participative decision-making, informed choices and autonomy during childbirth.
Procedure: Mutual Participation
Mutual participation during childbirth is the cornerstone of woman-centered care; it is a reciprocal process that facilitates collaboration and partnership, and this can be achieved through appropriate childbirth education programmes.
Context
The context is the childbirth unit of the hospital in the Capricorn district, Limpopo Province where the interaction takes place between the mother and the attending midwife during childbirth.
Dynamics
The dynamics that would facilitate the process of mutual participation is contained in the Batho-Pele philosophy and principles. The Batho-Pele Philosophy and Principles seek to introduce a customer-focused approach that aims to put pressure on systems, procedures, attitudes and behaviours within the childbirth units and reorients the attending midwives in the customer’s favour, an approach which puts the people first (Department of Public Service & Administration, 1997). These principles are outlined in Table 6.3:
115
Table 6.3: The Batho-Pele Philosophy and Principles Consultation
The Department of Public Service and Administration (1997) indicates that, consultation can help to foster a more participative decision making and cooperative relationship between the providers and the users of the public service. The shared decision making and more active involvement of consumers in their health could increase consumer perceptions of control which in turn could improve health outcomes (Breemhar & Van der Borne, 2001:4; Anon, 2002:373).
Service Standards
Service Standards refers to the aspect of service which is most important to the users. The users need to be informed about the service they are entitled to receive and about who is responsible for their care (Department of Public Service and Administration, 1997).
Access
Mothers should have access to skilled attending midwives during childbirth. Barriers to access, that is, social, cultural and communication need to be taken into consideration.
Courtesy
According to the Code of conduct for Public Servants issued by Public servants’ Commission, it is indicated that to ensure courtesy, midwives must treat mothers as ‘customers’ who are entitled to receive the highest standards of service.
Information
The sufficient, balanced, non-judgmental and appropriate information was found to be important at every stage of childbirth. Mothers were able to take decisions and express their informed preferences about their care (Flessing, 1993:71; Anon 2002:373). Those who felt ill informed during childbirth demonstrated the amount of anxiety caused by poor communication. Anon (2002:12) stated that it is evident that the level of mother’s knowledge contribute to the likelihood of participation in decision-making because information often reduce uncertainty and attenuates the difficulty in reaching the appropriate decision.
Openness and
The White Paper on Transforming Public Service (1997) indicated that the
Transparency
importance of the public service delivery lies in the need to build confidence and trust between the provider (midwife) and the user (mother).
Terminus/Goal for Woman-Centered Care
This was described in detail under the Goal (Section 6.3.1).
116
6.3.5.2 Process of the Model The model (Figure 6.3) depicts that through the procedure of facilitating mutual participation integrated within the Batho-Pele Principles (dynamics) the ‘womancentred care’ would be achieved. In the model, the arrows indicate this relationship. The process of providing woman-centred care during childbirth at a hospital, Capricorn district, Limpopo Province, will take place in three phases, namely: • Limited mutual participation (Dependency Phase 1) • Facilitation of mutual participation (Interdependence Phase 2) • Outcome (Independent Phase 3)
Phase 1: Limited Mutual Participation (Dependency Phase) The discussions of the empirical findings of Chapters 3 and 4 revealed that there were differences and similarities in the mothers’ and attending midwives’ experiences with regard to the following: • Mutual participation and responsibility sharing • Information sharing and empowering • Open communication and listening • Accommodative/non-accommodative
midwifery
actions
Hospital of the Capricorn district in Limpopo Province
at
the
117 CONTEXT: CHILDBIRTH UNIT
INTERACTION Midwife
Mother
1
C O N T E X T : C H I L D B I R T H U N I T
• • • • •
Limited mutual participation and responsibility sharing Limited information sharing and empowering Ineffective communication and limited physical comforting measures Non-accommodative midwifery action Limited human and material infrastructure.
Procedure Mutual Participation • Participative decision making • Interdependence and collaboration • Responsibility sharing • Information sharing and empowering • Accommodative midwifery actions • Maximize human and material
• • • •
2
Dynamics Batho-Pele Philosophy and Principles • Consultation • Service standards • Access • Courtesy • Information (childbirth education) • Openness and transparency
3
Terminus/ Goal Mutual participation and egalitarian relationship Equality with principle of power sharing Partnership and collaboration in decision making Well informed to enhance self-esteem, self-determination and self-reliant Independence
CONTEXT: CHILDBIRTH UNIT
Figure 6.3: Conceptual Model of Woman-Centered Care
C O N T E X T : C H I L D B R T H U N I T
118
Mutual Participation,
The results indicated
that there was limited
collaborative and
Responsibility Sharing
interdependent interaction during childbirth. Mothers relied on professional
and Decision-Making
and institutional expertise. Mothers’ participation in their care was limited
and Dependency
and they did not indicate/verbalize their preferences on arrival. Mothers would passively listen to attending midwives because they felt that midwives are trained practitioners and they know best.
Information Sharing,
With
regard
to
autonomy
mothers
displayed
limited
Empowering and
information/knowledge, understanding and awareness on what should
Autonomy
obtain during childbirth. This contributed to the inability to make informed choices during childbirth. When limited opportunities are created, mothers become powerless as evidenced by limited participation and responsibility sharing, decision-making ability, and dependency. When there is an exchange of information and knowledge between the mother and a midwife with regard to childbirth issues and available childbirth options mothers will become empowered.
Communication,
Language barrier was cited as a factor that interferes with the mothers’ and
Listening, Trust
midwives’ interaction during childbirth and midwives displayed limited
Relationship, Physical
listening skills.
Comfort and Emotional Support
Accommodative
Accommodative actions by midwives were to promote, support and respect
Midwifery Actions and
the values, beliefs and preferences of mothers as long as they are not
Shortage of Staff
harmful to the mother and baby. Presence of a companion during childbirth was supported although some policies and the ward environment need to accommodate be changed such a sanction. Both mothers and midwives cited shortage of staff as an issue of concern, since one midwife would be caring for more than two mothers at the same time. Midwives were not able to spent quality time with the mothers and verify their individual preferences.
119
Phase 2: Strategies to Enhance the Facilitation of Mutual Participation (Interdependence Phase) Chapter 2 of the Constitution of South Africa, through the Bill of Rights, give citizens the right to take action against the state if they believe their constitutional rights have been infringed and to have access to information held by the state (attending midwives an agent of the state) which they need in order to participate in decision-making, exercise informed choices, enjoy the benefits of autonomy, empowerement and independence (The Constitution, 1996:15). In line with these Constitutional Principles the facilitation of mutual participation is based on the assumption that the participants have virtually the same power, they need one another and that the shared activity will be satisfactory to both and both become active participants in the development of the nursing care plan (Pera & Van Tonder, 1996: 58). To realize the Bill of Rights, the Batho-Pele Principles as a Government initiative to put people first will be adapted in order to facilitate mutual participation between mothers and attending midwives during childbirth as follows: Consultation
Facilitation of consultation and participative decision-making is aimed at establishment of the childbirth education programme which is a clientcentred process that builds confidence and self-esteem to enable parents (mother) to take responsibility and control over their childbirth as active partners. It enables them to ask questions and seek information so that they can make informed choices and communicate effectively with the attending midwives (Nolan, 1997:1201; Nolte, 1998: 116). The goal of childbirth education programmes is to provide mothers with useful information on childbirth to acquire a sound knowledge to challenge the rationale of some of the procedures they are expected to undergo (Laryea, 1998:574). The childbirth education programme is the movement that focuses its attention on teaching women the medical definitions surrounding birth and to prepare mothers for hospital experiences (Turkel, 1990:54). When the mother plans to fall pregnant or when she is pregnant, she needs to consult with a midwife who will encourage her to attend the childbirth education programme. The midwife ought to create opportunities for the mother to become a partner. The techniques chosen for a particular mother will be based on needs assessment. During consultation the midwife is expected to respect mothers’ past experiences, plans and needs with regard
120 to their childbirth options. Equal Partnership
It is envisaged that through consultation and participative decision making
Between a Mother and
the following will be achieved: It is important that the environment that
Her Attending Midwife
fosters a trusting relationship be created. Partnerships require that there should be openness and transparency. Both the mother and the attending midwife should be actively involved in the development of the health education programme. The midwife should solicit the inputs of mothers when developing health education materials that are relevant to the contextual needs.
Participative Method
The most effective approach to use is interactive group with small numbers (Hill, 1993 cited in Swain & McNamara, 1997:267).
Health Education
Mothers should be encouraged to express their different points of view. The
Sessions and Focus
methods that can be used may include survey questionnaires, asking the
Group Discussions
mothers to voice their opinions and what they find useful about the childbirth education programme.
Establishment of Birth
During the discussion sessions mothers should be encouraged to make their
Plans
birth choices and plans before labour commences. According to Brown and Lumley (1998:106) deciding on birth plans is a strategy that enhances the involvement of mothers and their families in decision-making. They further stated that birth plans help to keep track of mothers’ preferences when multiple caregivers are involved. Birth plans are also a helpful vehicle for documenting and conveying to caregivers the needs and the preferences of mothers who are giving birth in an unfamiliar institution.
Principles of Access
When consultation takes place, these should be taken into consideration. These include the consideration of language barrier, literacy level and fear of authority as mothers may feel intimidated from expressing their true opinions if questioned by a midwife.
Personalised Care
When the mother didn’t attend the childbirth education programme, it is proposed that individual interviews be conducted with the mother on admission for delivery, to identify the mother’s preferences, choices and the midwife’s expectations
Service Standards
Service standards are commitments to provide a specified level and quality of service to individual customers at any given point in time (Department
121 of Public Service and Administration, 1997). In this study the experiences and needs that were revealed by the consultation process will be developed into precise and measurable standards for the mother to participate in her care as follows: •
Service standards should be expressed in terms which are relevant and easily understood by mothers (mothers should be able to judge for themselves whether or not they are receiving what was promised).
•
Service standards should cover mothers’ main requirements, for example, access (language), courtesy (respect) and provision of information (education).
•
Mothers must know and understand what quality of service they can expect to receive and what resources they have if the standard is not met.
•
The midwife should create opportunities to inform the mother about the results/ investigations/ procedures done to her and explain the reasons where the service has fallen short of what was promised (communication).
Access
The ‘White Paper on Transforming Public Service Delivery (1997) states that the service delivery programme should address the needs to progressively redress the disadvantages of all barriers to access. During the provision of midwifery care, barriers to access should be taken into consideration in order to facilitate mutual participation as follows: •
The attitude of the midwife should be approachable.
•
The midwife should respect, encourage and support mothers’ cultural and personal preferences and choices.
•
The style of language and choice of words used by the midwife should be carefully considered because words can reflect attitudes of respect or disrespect inclusion or exclusion, judgment or acceptance and can either ease or impede communication.
•
Encouragement of decision-making, autonomy, informed choices and personal control (except in situations of clear health risk).
Courtesy
Midwives have a powerful effect on mothers who are giving birth. They should be aware that their power to influence impacts both positively and negatively on the mothers’ childbirth experience. Mothers tend to
122 remember the specific words and actions of midwives and their satisfaction is linked to the type of care received, feelings of personal control and accomplishment. The midwives are expected to treat all mothers with courtesy, respect and dignity during childbirth. When mothers are treated with courtesy and respect during childbirth, they participate actively in their care. The following actions could be implemented to ensure that courtesy is taken into consideration: •
The Unit Managers should ensure that the values and behavioural norms of the units are in line with the Principles of Batho-Pele.
•
The performance of midwives who are in contact with mothers during childbirth must be regularly monitored and recorded.
•
Opportunities should be provided to midwives to suggest ways of improving midwifery care.
•
The training programme that includes day-to-day guidance should be developed in order to ensure that Batho-Pele Principles are implemented in the childbirth unit.
•
It is proposed that the midwife who renders care to the mother on admission in the hospital be the one who delivers the mother in order to strengthen the trusting relationship.
Information
Sharing of information is a mutual responsibility of the midwife and the mother. The consultation process should be used to find out what mothers need to know and where and when the information can be best provided. This could be achieved through the following actions: •
The
midwives
should
provide
accurate
and
up-to-date
information about the childbirth process, explain it fully by presenting the pros and cons about the care they would provide. •
When providing information, individual or group teaching methods should be adopted.
•
Information should be provided in the mothers’ own language (access) to be relevant in order to meet the needs of the mother.
•
The information should be made simple in order to maximize its comprehension and minimize any potential imposition of the attending midwife’s view.
•
When presenting information to mothers an interval should elapse between the presentation of advantages and disadvantages of the
123 proposed treatment and patient decision, to ask further questions (Wright, McCrea, Stringer et al., 2000:1169). •
The benefits and the risks of all the procedures need to be disclosed and explained, as well as the all options that a mother might consider. The midwives need to provide time, support and encouragement to mother for exploration of various options.
•
The written information should be plain and free from jargon and be supported by graphical material as this might make it easier to understand. Laryea (1998:570) supported this idea, stating that visual aids could be used, and this should include slides, films and videos to clarify the verbal information, but cultural relevance should also be considered.
•
Handouts on specific topics could be supplied as a method of informing mothers during childbirth.
•
Information about the available services should be made known to mothers.
•
When all relevant information has been made available to the mother for, the achievement of her goals, she should be guided and not directed by the midwife to share the responsibility for her care during childbirth.
•
Information was shared between the mother and the attending midwife is valued by mothers. Ho and Holroyd (2002:80) indicated that mothers viewed attending of classes as a type of insurance because it enables them to feel more secure.
•
The content of childbirth education programmes should be adapted to the needs of the mother and could cover the following: ¾
Anatomical, physiological, psychological and emotional changes during pregnancy, labour and pueperium, including changes that could affect the partner
¾
Prevention and early detection of complications of childbirth
¾
Management and care of minor illnesses encountered during pregnancy, labour and pueperium
¾
Pain relief during labour
¾
Orientation with regard to the physical surroundings of the
124 labour ward ¾
Orientation to different techniques used in hospital
¾
Orientation to basic routines of the hospital
¾
All other aspect of pregnancy, labour and pueperium (adapted from Nolte, 1998:120).
However, Nolan (1997:1201) pointed out that it is very unlikely that the childbirth education programme, as it is currently on offer is making a significant contribution towards putting most women at the centre of their own care and enabling them to participate in decision-making about the management of their childbirth.
Openness and
The White Paper on Transforming the Public Service (1997) indicated that
Transparency
the importance of the public service delivery lies in the need to build confidence and trust between the provider (midwife) and the user (mother). Pera and Van Tonder (1996:61) indicated that the most satisfactory relationship between the nurse and the patient is characterized by mutual trust and further pointed out that trust forms the basis of a successful and effective health care relationship.
Encourage Consultation
Through consultation, the mothers will understand the type of service to be received and its accessibility, feel respected and informed, mothers will be confident and a trusting relationship will be enhanced. Mothers will feel as partners during childbirth.
Formation of
The partnership will be displayed by mutual participation and responsibility
Partnerships
sharing, increased decision-making ability, ability to make choices and exercise autonomy, information sharing and being empowered and forming an interdependent relationship. In the Annual Report for Service User Involvement (2000-2001:1) it was indicated that mothers would be fully informed and involved in the plan that is tailor-made for their care. The proposed actions would facilitate the provision of woman-centred childbirth care in the Capricorn district of the Limpopo Province. The results of the study by Bechell, Myers and Smith (2000:402) showed that the hospital units that were more patient-centred were associated with statistically significant better outcomes than those that were less patientcentred.
125
Phase 3: Outcome (Independence Phase) There is enough evidence indicating that patients wish to collaborate with their physicians through discussion, information sharing and mutual decision-making when they are adequately informed (Kim, Smith & Yuego, 1999:259). Womancentred care is not something that will develop overnight; it will take practice, continued childbirth and in-service education programmes to mothers and their attending midwives. The outcome/goal of the woman-centred care approach during childbirth would strive to achieve the following: • Participation that requires a mutual, egalitarian and respectful relationship. • Equality that includes the principle of sharing power and responsibility • Negotiation between the mother and the midwife to form a partnership. Pera and Van Tonder (1996:62) stated that within a partnership the attending midwives and mothers share responsibility in decision-making. Pearson et al (1998:54) are in agreement with the notion that the attending midwife ought to operate as a partner with the mother during childbirth rather than a director of childbirth to the mother. • The provision of sufficient information will be a prerequisite for decision-making that enhances self-esteem and self-determination of the mother. • The mother and midwife would listen to each other because they engage in a dialogue to identify preferences and expectations. Pera and Van Tonder (1996:60) referred to this as therapeutic reciprocity. This would be achieved through a ‘woman-centered childbirth model’ aim at facilitating mutual participation during childbirth.
126
6.3.6 Assumptions Assumptions are based on Batho-Pele Principles (Department of Public Service & Administration, 1997) which indicate that public servants (attending midwives) are expected to treat all citizens (mothers) with courtesy, respect and dignity. The Batho-Pele Principles and the manner in which they will be integrated in the conceptual model has been described under Dynamics (Section 6.3.5).
6.4
EVALUATION OF THE MODEL
The guidelines for critical reflection of theory from Chinn and Kramer (1995:134135) will be followed to evaluate this model: How Clear is the Model?
The definitions of concepts through the process of concept analysis were done in order to ensure the semantic clarity.
How Simple is the Model?
The overall structure of the woman-centered childbirth model could be followed by using the visual diagram. The major concepts of the model were defined and it was ensured that basic assumptions are consistent with each other. The model is simple because its use could improve midwifery practice.
How General is the Model?
The breadth of scope and the purpose of the model could be used in midwifery setting and other health care settings with the aim of enhancing mutual participation and responsibility
sharing,
information
sharing
and
empowering. How Accessible is this Model?
The model would be accessible because it has attempted to explain the existing experiences and also predicted that integration and implementation of Batho-Pele Principles in midwifery practice would facilitate mutual participation and improve midwifery practice.
How important is the model?
Since the model is closely tied to the idea of its practical value, the woman-centred childbirth model, if utilized, could improve the practice of midwifery by enhancing
127 mutual participation and responsibility sharing, information sharing and empowering during childbirth. Does the Model Display the Researcher’s The model was originally created by the researcher with the Original Contribution?
aim of strengthening the mutual participation of mothers during childbirth. The promoter who holds a doctoral degree in Midwifery Nursing Science and who is experienced in qualitative research and theory generation will execute the final evaluation of this model. Secondly, the group of experts in qualitative research and theory generation will evaluate the model during presentation at a seminar.
6.5
FORMULATION OF CRITERIA FOR WOMAN-CENTERED CARE
The criteria derived from concept analysis make it possible to adequately construct or recognize the occurrences of other instances. Chinn et al. (1987:98) pointed out that criteria specify the characteristics typically present whenever the object, property or event occurs. Muller (2002:207) stated that criteria are refined dimensions of interest that can actually be measured. Anon (2002) support this view that criteria have been defined as standards by which action can be measured. According to Muller (2002:204), there are three different types of standards, that is, structure, process and outcome. For this study the researcher will adapt the structure type when formulating the criteria for woman-centered care. A structure standard describes what is required for performance of an action or nursing act (Muller, 2002:204). In this study this will refer to the minimum that is required to enable the implementation of Batho-Pele Principles in the childbirth unit. In attempting to develop criteria, three basic questions need to be answered, that is, what to measure, where to measure and how to measure. The empirical referents of woman-centered care as outlined in Section 6.2.7. The Batho-Pele Principles will be utilized when formulating the criteria for womancentered care. The empirical referents will be integrated with the Batho-Pele Principles as outlined by Department of Public Service and Administration (1997).
128
TABLE 6.4: Criteria for Woman-Centered Care CRITERION 1 The attending midwife demonstrates the skill of facilitating mutual participation and responsibility sharing by integrating the Batho-Pele Principles during childbirth. There is evidence of facilitating mutual participation and responsibility sharing through the implementation of Batho-Pele principles by: 1.
Ensuring that an environment created that foster a trusting relationship by openness and transparency.
2.
Treating mothers as individuals who themselves and their own mental health, encouraging them to express their views and their views which are taken into account in the decisions made about their care.
3.
Undertaking consultation by considering sensitivity, and not asking mothers to reveal unnecessary personal information.
4.
Ensuring the availability of a written, comprehensive nursing care plan that indicates the assessment of the needs of the mothers to sort mother’s preferences and choices and midwife’s expectations.
5.
Involving mothers in the planning, implementation and evaluation of midwifery care and to accommodate their preferences.
6.
Consulting mothers by determining what they want, through the use of questionnaires and by asking mothers’ opinions.
7.
Utilizing birth plans for mothers to indicate their choices during childbirth.
8.
Displaying enhancement of autonomy where the attending midwife informs the mother on benefits and risks of treatment and allowing the mother to decide.
9.
Ensuring that mothers are aware of and understand what quality of service they can expect to receive and what resources they have if standards are not met.
Yes
No
Remarks
129 10.
Creating opportunities to inform the mother about the results/investigations or procedures done to her.
11.
Ensuring that feedbacks are done by regular interviews, surveys and questionnaires, suggestion boxes or comment cards as these assist in improving service provision.
12.
Scheduling monthly/quarterly hour meetings with mothers or inviting them to be part of representatives when service delivery issues, standards and problems are discussed and to give feedback.
13.
Encouraging mothers’ decision making, autonomy, informed choices and personal control (except in cases of clear health risk).
14.
Inclusion of the representative of mothers in maternal and newborn committees, to develop education material or to review the written drafts on protocols to be implemented within the unit.
15.
Publicizing the results of consultation within the unit so that the attending midwives are aware of how their services are perceived.
16.
Conduct consultation and not list demands that raise unrealistic expectations.
17.
Ensuring courtesy by addressing mothers by their names. CRITERION 2
The attending midwife demonstrates the skill of sharing/exchanging of information and empowering by integrating the Batho-Pele Principles during childbirth. There is evidence of exchange of accurate and up-to-date information about childbirth issues and available options through the implementation of Batho-Pele Principles by: 1.
Consulting mothers to find out what they need to know, work out how, where and when information can be best provided.
2.
Giving information that is client-centred as this would build confidence, selfesteem and will enable the mother to take responsibility.
Yes
No
Remarks
130 3.
Ensuring that information is guided and not directed for mothers to share responsibility.
4.
Providing information in mother’s language own and ensuring that it is relevant to her needs and that the tone used is not patronizing.
5.
Ensuring that provision of information is clear, simple and detailed to maximize its comprehension and minimize any potential imposition of the attending midwife’s views.
6.
Ensuring that written information is plain and free from jargon and is supported by visual aids.
7.
Ensuring that provision of information discloses all the benefits and risks of all procedures as well as all options that a mother might consider.
8.
Ensuring that during information sharing time is offered for mothers to explore various options and opportunity is offered for the mother to ask questions.
9.
Soliciting the mothers’ inputs when developing health education materials that are relevant.
10.
Ensuring that mothers are respected as individuals during information sharing, attention is paid to fostering dignity, selfesteem and to provide privacy and confidentiality.
11.
Ensuring that mothers understand the type of service to be received, where to get information, its accessibility and the name and contact of the person for obtaining further information and advice.
12.
Ensuring that mothers are informed on what resources are available if standards are not met.
13.
Ensuring that the training and childbirth education programme that empowers the mother are developed and utilized in childbirth units.
14.
Evaluating by assessing client satisfaction following education, that is, can mothers express informed preferences.
131 CRITERION 3 The attending midwife demonstrates the attitudes and skills of enhancing open communication and listening by integrating the Batho-Pele Principles during childbirth. There is evidence of open communication and listening between the mothers and attending midwives during childbirth through the implementation of Batho-Pele Principles by: 1.
Displaying of an approachable attitude, empathy, and courtesy by attending midwives.
2.
Treating mothers as customers, that is, listening to their views and taking account of them in making decisions about what childbirth services should provide.
3.
Respecting mothers’ experiences, plans and needs.
4.
Minimizing language barriers by choosing the style of language and choice of words as these can reflect an attitude of respect or disrespect and can impede or ease communication.
5.
Considering cultural acceptability, cultural barriers to health care relating to the lack of autonomy and decisionmaking power which often constrain women’s access to health care.
6.
Listening and encouraging mothers to express their different points of view.
7.
Building confidence and trust during childbirth by openness and transparency.
8.
Wearing of name tags/badges by the attending midwives for mothers to know the midwife who is providing care to her as this will ease communication.
Yes
No
Remarks
132 CRITERION 4 The attending midwife demonstrates the skill of accommodating mothers’ choices and preferences by integrating the Batho-Pele Principles during childbirth. There is evidence of accommodating mothers’ choices and preferences during childbirth through the implementation of the Batho-Pele Principles by: 1.
Respecting (all concerns and opinions), supporting of cultural norms, personal preferences and choices by asking the experiences, plans and needs of mothers.
2.
Providing flexible policies that accommodate planning and decisionmaking by mothers during childbirth.
3.
Developing policies (protocols) to provide woman-centered care, or integrate them into the existing framework.
4.
Developing the protocols and make them available, outlining all levels of health care.
5.
Developing Departmental codes and training programmes that integrate BathoPele Principles to ensure that mothers are treated with courtesy, respect and dignity.
6.
Involving family members (companion) in the care of the mother, as this could intensify the mother’s perception of control during childbirth.
Yes
No
Remarks
CRITERION 5 The attending midwife demonstrates the skill of maximizing the human and material infrastructure through the integration of the Batho-Pele Principles during childbirth. There is evidence of maximizing the human and material infrastructure during childbirth through the implementation of the Batho-Pele Principles by: 1.
Allocating adequate staff to provide quality midwifery care to mothers during childbirth.
2.
Ensuring that the staff are assigned clear roles and have rights to work in a supportive and protective environment.
3.
Ensuring that staff utilizes the midwifery resources efficiently, economically and effectively in order to provide the quality
Yes
No
Remarks
133 midwifery care. 4.
Monitoring regularly and recording the performance of the attending midwives who are in contact with mothers during childbirth
5.
Ensuring that the technology is used judiciously, appropriately and only if a benefit has been demonstrated and not used unnecessary as this may distract the mother.
6.
Availing of the written values and behavioural norms of the unit that are in line with the Batho-Pele Principles.
7.
Availing of the standards that are expressed in terms which are relevant, and easily understood by mothers for them to understand the type of service to be received.
8.
Ensuring that opportunities are provided to the attending midwives to suggest ways of improving the midwifery care.
9.
Ensuring that there is accurate and proper record keeping by the attending midwives to improve midwifery care.
6.6
SUMMARY
In this chapter, the process of concept analysis for woman-centered care was conducted in order to identify the connotations of the concept. To realize how the concept fit within the midwifery practice, the conceptual model of woman-centered care was developed. The model could be utilized in the facilitation of mutual participation during childbirth in the childbirth units in the Limpopo Province. The criteria for evaluating the model were described. Finally, the empirical referents of the concepts were used to formulate the criteria. In Chapter 7, the conclusions, validation, limitations and recommendations of the study will be described.
134
CHAPTER 7 CONCLUSIONS, VALIDATION, LIMITATIONS AND RECOMMENDATIONS OF THE STUDY
7.1
INTRODUCTION
The previous Chapter dealt with the following: concept analysis of woman-centered care, description of the structure and process of a woman-centered childbirth model and the formulation of criteria for woman-centered care. The formulated criteria, strategies for implementing the model and evaluation of the model were described. This chapter will review whether the objectives of study have been met and validate whether the developed model, strategies and criteria can be applicable to midwifery practice. The recommendations for the implementation of the model, and criteria in maternity, obstetrics and neonatal, general nursing science, research and Department of Health, Maternal and Child Health Directorate, and all other institutions where there is interaction to facilitate mutual participation between a mother and a midwife will be described.
7.2
CONCLUSIONS OF THE STUDY
The overall purpose of the study has been to determine the experiences of childbirth by mothers and their attending midwives in order to develop the women-centered childbirth model and criteria. The Batho-Pele Principles as outlined in the Department of Public Service and Administration (1997) will be integrated within the model strategies and the criteria. These would attempt to enhance mutual participation between mothers and all attending midwives during childbirth in a Hospital at Capricorn district, Limpopo Province.
135
This process was achieved through the:
• Description and exploration of mothers’ experiences of childbirth. • Description and exploration of attending midwives’ experiences on managing mothers during childbirth. • Development and description of women-centered childbirth model that will be utilized to assist the attending midwives in the facilitation of mutual participation when managing mothers during childbirth. • Formulation of the criteria for woman-centered care that will be used as an institutional self-evaluation tool to enhance the implementation of the BathoPele Principles.
The first and the second objectives were met by making use of a qualitative approach, which is exploratory, descriptive, contextual, and inductive in nature. The in-depth unstructured interviews, participant observation using an observation guide, visual analog scale (VAS) and unstructured conversations were used as data collection methods. Data were collected from twenty-four (24) mothers and twelve (12) attending midwives in the obstetric and postnatal units of one hospital, Capricorn district of the Limpopo Province. The results of mothers’ and midwives’ interviews were subsequently analyzed and categorized and woman-centered care emerged as a core category. The third and the forth objectives were met by utilizing the information obtained from data analysis to conduct concept analysis of a core category, develop a woman-centered childbirth model and to formulate the criteria for woman-centered care.
136
A brief summary of chapters in this thesis follow: Chapter 1
Description Chapter 1 as an orientation formed the structural point of reference for the whole study. The purpose of the study was to explore and describe the experiences of mothers of childbirth and that of attending midwives of managing mothers during childbirth. The findings provided the basis for developing and describing a model for woman-centered childbirth and the formulation of the criteria for woman-centered care for the a Hospital in the Capricorn district of Limpopo Province.
2
Chapter 2 of this study dealt with the detailed description of the research design and method.
3
Chapter 3 dealt with the discussion of the research results of the interviews conducted with mothers regarding their experiences of childbirth.
4
Chapter 4 focused on the discussion of the research results of the interviews conducted with attending midwives regarding their experiences on managing mothers during childbirth.
5
Chapter 5 focused on combining the mothers’ and the attending midwives’ results, discussing and clustering the results from empirical data and supporting the results by means of literature control. The results of the research revealed a core category as ‘woman-centred care’ and five (5) categories namely. ¾ Mutual Participation and Responsibility Sharing ¾ Information Sharing and Empowering
137
¾ Open Communication and Listening ¾ Accommodative/Non-Accommodative Midwifery Actions ¾ Maximize Human and Material Infrastructure From both the mothers’ and the attending midwives’ fieldwork results it became clear that mutual participation and responsibility sharing, interdependence, information sharing and empowering activities, need to be enhanced during childbirth. To achieve this, it was evident that the experiences that foster/promote dependency during childbirth as identified in the fieldwork be replaced by factors that characterized woman-centred care during childbirth in a Hospital at the Capricorn district, Limpopo Province.
6
Chapter 6 dealt with the concept analysis of the core category which was followed by the development of the structure, process and outcome of a woman-centered childbirth model, formulation of criteria for woman-centered care and lastly the evaluation of the model was described. The concept analysis utilized the framework as described by Walker and Avant (1995). The steps involved were: ¾ Select a Concept ¾ Aims of Analysis ¾ Identify Uses, Characteristics or Connotations of the Concept ¾ Determine Defining Attributes ¾ Develop the Model Cases ¾ Identify Antecedents and Consequences ¾ Define Empirical Referents
138
The development and description of women-centered childbirth model that will be utilized to assist the attending midwives in the facilitation of mutual participation of mothers during childbirth was done. During the development of the model, concepts that were identified as enhancing woman-centered care were as follows: ¾ Mutual Participation and Responsibility Sharing ¾ Information Sharing and Empowering Activities ¾ Effective Communication and Adequate Physical Comforting Measures ¾ Accommodative Midwifery Actions ¾ Maximizing of Human, Material Infrastructure
Assumptions of the concepts were identified and conceptualized within Batho-Pele Principles as outlined in the Department of Public Service and Administration (1997). The structural form and process of the model were described. The formulation of the criteria for woman-centered care that will be used as an institutional selfevaluation tool to enhance the implementation of the Batho-Pele Principles emerged as empirical referents. The model will be validated by the subject experts for applicability and presented to the theory generation experts for further clarification and refinement.
7
Chapter 7 will focus on the conclusions, validation of the model, strategies and criteria, limitations and recommendations of the study. The woman-centered childbirth model with strategies and the criteria of woman-centered care were discussed in Chapter 6. Validation will be done in consultation with all stakeholders involved in midwifery care that is, nursing education, nursing
139
practice, nursing management and policy makers before these can be adopted and implemented in the childbirth units in the Limpopo Province.
7.3
VALIDATION OF THE DEVELOPED MODEL, STRATEGIES AND CRITERIA
Validation is the method for determining the credibility of empirical knowledge in relation to a scientific model of a discipline (Chinn & Jacobs, 1987:13). Irobi, Andersson and Wall (n.d:2) described validation as taking decision as to whether the model in question is valid. They further pointed out in page 3 that validation assures that a model contains the features imputed to it in their description, which implies that it is well grounded, sound or capable of being justified. The purpose of validation for this study is to identify the value and potential contributions this model, strategies and criteria could make for the provision of woman-centered care. The second purpose is to close the identified gaps and correct the inconsistencies in the provision of midwifery care.
7.3.1
Methodology for Validation Process
7.3.1.1 Sampling A purposive sampling technique was used to select the participants. Purposive sampling is a type of non-probability which is collected from a group of respondents chosen for a specific key characteristic (Sells, 1997:172). The researcher used her judgment to select the participants who had most characteristics, attributes and represented the different categories to validate the model and strategies for implementation.
140
Specific Criteria for Inclusion
Nursing
3 Lecturers who are teaching Midwifery Nursing
Education:
Science, one (each) from three South African Universities
(University
of
Kwa-Zulu
Natal,
University of Venda and University of the North). Policy Makers:
2 Officials from the Maternal, Child and Women’s Health (MCWH) Directorate in the Department of Health, Limpopo Province.
Nursing
2 Managers who are allocated for supervisory role in
Management:
childbirth unit at the (tertiary) hospital.
Nursing Practice:
5 Midwives who are providing midwifery care to mothers during childbirth at a hospital.
Although this is a subjective method of sampling, for validation it was necessary to include midwifery experts, policy makers, unit managers (supervisors) and providers of midwifery care, all these participants are involved in teaching, planning and provision of childbirth care.
7.3.1.2 Preparation for Data Collection The validation tools (checklist) were developed for all participants (Addenda 7 and 8 and Table 6.4). Midwifery experts were to validate the developed model (Figure 6.3 and section 6.3.5.2). The policy makers, unit managers and the providers of midwifery care were to validate the formulated strategies (Phase 2 of section 6.3.5.2) and the formulated criteria (Table 6.4). Copies of the developed strategies and criteria were personally delivered to all participants. An appointment was made for semi-structured interview with the policy makers and managers and the focus group discussion with the providers of midwifery care. Ethical considerations were observed.
141
7.3.2 Data Collection for the Midwifery Experts An informal validation was followed to collect data from the midwifery experts. Chinn and Jacobs (1987:13) referred to this as the validation of empirical knowledge by noting and sharing convictions about applicability of the model to the discipline without formally testing these convictions using methods of research. The copy of the developed model was posted to each participant who had consented to participate. The experts were to validate whether the model is adequate, accurate and represents reality for it to be assumed effective in achieving the goal if applied in midwifery practice. This was also done to ensure that the model has intersubjective certifiability. Chinn and Jacobs (1987:177-180) outlined the prerequisites to be considered before application of the theory/model in practice as: • Theory Goal and Practice Goal Relationship • Situational Factors • Theory Variables and Practice Variables • Nursing Actions and Research Evidence These prerequisites were adapted for this study in order to make a sound judgment regarding application of the theory/model.
Responses of the Three (3) Midwifery Experts The responses of the model validation were: A. Theory Goal and Practice Goal Relationship Is/does the goal of this model
Consensus were reached, all the participants agreed
judged to be of value in nursing
that this model will be of value in the midwifery
practice?
practice.
When
applied
to
practice,
mutual
participation and responsibility sharing will be enhanced during childbirth. Is the theoretical goal of the
All the participants are accord that the theoretical goal
model consistent with the goal
of the model is consistent with the goal of optimal health. Because the model may enhance self-esteem,
142 of optimal health?
self-determination and self-reliance of the mother during childbirth.
Is operational validity ensured
There were consensus with regard to model output,
so that the model output has
however,
enough accuracy for its
interdependence rather than independence.
suggestions
were
that
outcome
be
intended purpose?
B. Situational Factors Is the model congruent with the
All participants conceded that the model is congruent
situation where it will be
with the situation where it will be applied because
applied?
woman-centered care is applicable to the childbirth context.
C. Theory Variables and Practice Variables Does the model describe the
There were consensuses that the model described
phenomenon under study?
woman-centered care, within the childbirth context.
Are practice variables included
There were concords amongst all participants that the
in the theoretical relationship
antecedents, defining attributes and consequences of
statements?
the
model
were
included
in
the
relationship
statements.
D. Nursing Actions Does the relationship within the
All participants acknowledged that the model provides
model offer sufficient
sufficient
explanation to provide a basis
implementation of midwifery actions. The strategies
for planning and
to implement the model were described in detail
implementation of midwifery
(Section 6.3.5.2, Phase 2).
actions?
explanation
for
the
planning
and
143 Does the model provide
All participants agreed that the model provided
explanation for the
explanation that limited mutual participation and
phenomenon and predictions of
responsibility
sharing,
the outcome?
empowering
activities
limited lead
information to
and
ineffective
communication, powerlessness and dependency. provide
Consensuses were reached that through the integration
direction for nursing actions
of the Batho-Pele Principles in midwifery practices
needed?
that woman-centered care will be achieved. Strategies
Does
the
model
were described (Section 6.3.5.2, Phase 2).
E. Research Evidence Does the model provide
Consensus opinion was that there is sufficient
research evidence to support
evidence of literature control and review (Section 6.3)
the theoretical/ model
to justify the theoretical/model formation.
formation? Is the research evidence
Two participants agreed that there is research
sufficient to justify the
evidence and one participant pointed out that this
implementation of this model in
model is specific to a particular context. A further
practice?
study could be recommended for the other context.
7.3.3 Planning for Application of the Theory/Model According to Chinn and Jacobs (1987:179), before making application of the theory/model, the researcher needs to assess the potential for observing and recording factors that are relevant to model’s application. Questions to be asked in planning for application include: • Do attending midwives need to be oriented to the model and its application? • What practical arrangements and material needed to enhance the ease and accuracy of making and recording observations?
144
• How will pilot application affect other activities in the childbirth unit? • Are special provisions needed for gathering and storing information? • How will the mothers be informed regarding the model that will be used? • How will the data that are obtained be assessed and analyzed? • If the theoretical (model) goal is attained or not attained, how will the results be explained or accounted for? • Have alternative explanations been projected in order to have sufficient information to make this judgment? • How will the results of the experience be compiled in order to communicate them to others? If each of these questions can be answered in such a way that application seems feasible and desirable, application is probably indicated. In the context of this study, the pilot study using the abovementioned questions need to be conducted so that the results will be evidence to suggest application of this model in the childbirth units in the Limpopo Province.
7.3.4
Data Collection for Policy Makers, Unit Managers and Midwifery Care Providers
7.3.4.1 Developed Strategies The semi-structured face-to-face interviews were conducted for about 45 minutes with the policy makers and unit managers at their respective offices and one focus group discussion was undertaken with the providers of midwifery care. The focus group discussion took place in the duty room at the obstetrical unit for about 30 minutes. The aim of the interviews was to make changes and modifications to the strategies,
where
applicable,
before
these
could
be
recommended
for
implementation in childbirth units in the Limpopo Province. The copy of the developed strategies that was forwarded to each participant was discussed using an
145
interview schedule guide for all the participants (Addendum 8) in order to encourage conversation. Permission was obtained to use the tape recorder to capture everyone’s suggestion. The aim was to validate whether the formulated strategies were: • Applicable and relevant to enhance the provision of woman-centered care. • Appropriately integrated within Batho-Pele Principles in order to facilitate the mutual participation during childbirth.
Responses of the policy makers, unit managers and the providers of midwifery care (9 participants) are detailed below.
THE RESPONSES OF VALIDATION OF THE STRATEGIES WERE DISCUSSED AS FOLLOWS:
STRATEGY 1 Facilitate Mutual Participation and Responsibility Sharing by Integrating Batho-Pele Principles During Childbirth Does the strategy
All the participants agreed that this strategy has the potential
enhance the provision of
for enhancing the provision of woman-centered care. The
woman-centered care?
emphasis of the strategy is to create the opportunities for enhancing mutual participation and responsibility sharing during childbirth. Mothers’ participation should be based on a collaborative relationship and partnership.
Batho-Pele
Consensus was reached by all participants that all the Batho-
Principles appropriately
Pele Principles are appropriately integrated within this
integrated
strategy. This integration will facilitate the putting of these
Are
the
in
this
strategy?
principles into midwifery practice.
Are there gaps and
7 Participants indicated that there were no gaps and
inconsistencies in the
inconsistencies in the implementation of this strategy, whereas
146 implementation of this
2 participants indicated that, with consultation:
strategy?
•
Midwives need to be given in-service education on the implementation of birth plans.
•
It is difficult to have an hour meeting with the mothers in the hospital, but the use of suggestion boxes could serve the same purpose
STRATEGY 2 Sharing/Exchanging of Information and Empowering by Integrating the Batho-Pele Principles During Childbirth Does the strategy
All the participants agreed that this enhances the provision of
enhance the provision of
woman-centered care, because it facilitates the creation of
woman-centered care?
opportunities of information provision and sharing. Provision of sufficient information is a pre-requisite for informed decision-making during childbirth.
Are
the
Batho-Pele
Principles appropriately integrated
in
All participants are agreed that all the Batho-Pele Principles are appropriately integrated within this strategy.
this
strategy?
Are there gaps and
All participants indicated that there are no gaps and
inconsistencies in the
inconsistencies in the implementation of this strategy.
implementation of this strategy?
STRATEGY 3 Enhancing Open Communication and Listening by Integrating the Batho-Pele Principles During Childbirth. Does the strategy
All participants agreed that this strategy enhances the
enhance the provision of
provision of woman-centered care, it emphasizes that mothers
147 woman-centered care?
and attending midwives should listen to each other, engage in dialogue to identify preferences and expectations. Listening facilitate openness and mutual participation.
Batho-Pele
All participants agreed that the Batho-Pele Principles are
Principles appropriately
appropriately integrated in this strategy. The emphasis on
integrated
access (approachability, cultural, literacy, language, trusting
Are
the
in
this
relationship
strategy?
and
name
tags)
would
enhance
open
communication and listening between the mother and the attending midwife during childbirth. Are there gaps and
All participants indicated that there are no gaps and
inconsistencies in the
inconsistencies in the implementation of this strategy.
implementation of this strategy?
STRATEGY 4 Accommodate Mother’s Choices and Preferences by Integrating the Batho-Pele Principles During Childbirth. Does the strategy
The consensus was reached by all participants that the strategy
enhance the provision of
enhances the provision of woman-centered care the activities
woman-centered care?
provide for respect, individualized care and emotional involvement during childbirth.
Batho-Pele
All participants agreed that the Batho-Pele Principles are
Principles appropriately
appropriately integrated in this strategy, because it is clearly
integrated
indicated that a mother as a customer is consulted and
Are
the
in
this
strategy?
encouraged to participate in her care. A provision to consider choices and preferences about services offered and equal access to personal control and decision-making are made in this strategy.
Are there gaps and
Five participants did not indicate anything about gaps and
inconsistencies in the
inconsistencies whereas four Participants indicated that there
148 implementation of this
are gaps and inconsistencies in the implementation of this
strategy?
strategy, because in practice it is difficult to accommodate the mother’s preferences due to the ward environment and limited skills of attending midwives.
STRATEGY 5 Maximize the Human and Material Infrastructure by Integrating Batho-Pele Principles During Childbirth Does the strategy
All participants agreed that this strategy enhances the
enhance the provision of
provision of woman-centered care and by the utilization of
woman-centered care?
birth plans participative decision making is enhanced. Mothers will understand what care to receive and what resources they have if the standard is not met.
Batho-Pele
All participants agreed that the Batho-Pele Principles are
Principles appropriately
appropriately integrated in this strategy, because it was pointed
integrated
out that these principles should also apply to the attending
Are
the
in
this
strategy?
midwife. The role of the midwife is clear, the opportunities created for in-service education will assist for the provision of efficient, effective and quality midwifery care by midwives.
Are there gaps and
All participants indicated that there are no gaps and
inconsistencies in the
inconsistencies in the implementation of this strategy.
implementation of this
However, the practice is faced with challenges of staff
strategy?
shortage.
7.3.4.2 Formulated criteria The copy of the formulated criteria (Table 6.4) that was forwarded to each participant to complete was collected after conducting the interviews. The aim for completing was to make changes and modifications to the formulated criteria, where
149
applicable, before these could be recommended for implementation in childbirth units in the Limpopo Province. The criteria were validated whether they are: • Applicable and relevant to enhance the provision of woman-centered care in childbirth units. • Appropriately integrated within Batho-Pele Principles in order to facilitate the mutual participation during childbirth.
THE RESPONSES OF VALIDATION OF THE CRITERIA WERE DISCUSSED AS FOLLOWS:
All 9 (100%) participants (2 policy makers, 2 unit managers and 5 midwifery providers) strongly agreed by ticking yes that all five formulated criteria were: • Applicable and relevant to enhance the provision of woman-centered care in childbirth units. • Appropriately integrated within Batho-Pele Principles in order to facilitate the mutual participation during childbirth.
The comments from the participants indicated that they were happy about the descriptions of the strategies and criteria as these descriptions were real representations of how they prefer the woman-centered care to be provided in the Limpopo Province. These comments contribute to the truth value (credibility) of the study. Three (3) experts of midwifery and nine (9) other participants (2 policy makers, 2 unit managers and 5 providers of midwifery care) were granted opportunities to make suggestions/comments that could contribute to the finalization of the model, strategies and criteria respectively.
150 Model
N=3 (100%) of the lecturers involved in teaching Midwifery Nursing Science agreed that model is applicable to midwifery practice with suggestion that the outcome be interdependence rather than independence. Replication study would be conducted for the model to be applied in other contexts in Limpopo Province.
Strategies N=7 (100%) of unit managers and providers of midwifery care. All the participants agreed that these strategies should be suggested for implementation to the Directorate of Maternal, Child and Woman’s Health as a measure of enhancing the facilitation of mutual participation and responsibility sharing during childbirth. N=2 (100%) of midwives (Policy Makers) from the Directorate of Maternal, Child and Woman’s Health who are involved in policy making on activities and programmes relating to mother, child and women’s health agreed that all the strategies would assist in enhancing the provision of woman-centered care in the Limpopo Province. Criteria
N=7 (100%) of unit managers and providers of midwifery care strongly agreed that all five formulated criteria were applicable and relevant to enhance the provision of woman-centered care in childbirth units and are appropriately integrated within Batho-Pele Principles in order to facilitate the mutual participation during childbirth. N=2 (100%) of midwives (Policy Makers) from the Directorate of Maternal, Child and Woman’s Health who are involved in policy making on activities and programmes relating to mother, child and women’s health strongly agreed that all five formulated criteria were applicable and relevant to enhance the provision of woman-centered care in childbirth units and are appropriately integrated within Batho-Pele Principles in order to facilitate the mutual participation during childbirth.
Therefore, it can be concluded by stating that all the stakeholders reached consensus on the proposed model, strategies and criteria respectively. They agreed that these should be recommended and be implemented in the Capricorn district, as a pilot (practical validation). Chinn and Jacobs (1987:165) pointed out that the theory testing research has immediate practice application. By conducting/replicating the
151
study to other districts in the Limpopo Province at a later stage, the results may further suggest revision or recommendations for application.
7.4
THE GOALS AND CONCLUSIONS OF THE APPLICATION OF THE MODEL, INTERVENTION STRATEGIES AND CRITERIA
The goals of the model and strategies were aimed at enhancing the provision of woman-centered care which would facilitate mutual participation and responsibility sharing, creation of opportunities for information sharing and empowering, open communication and listening, accommodative midwifery actions and maximizing of human and material infrastructure during childbirth. The formulated criteria will be used as an institutional self-evaluation tool to enhance the implementation of the Batho-Pele Principles.
7.5
LIMITATIONS
A number of limitations to this study were identified as: • Most mothers were skeptical about sharing their experiences of childbirth, because of fearing that they might be victimized because the in-depth unstructured interviews were conducted while mothers were still in the postnatal ward (not in labour ward). Mothers were requested to share experience of childbirth (1st-3rd of labour) and not of postnatal care and participation were voluntary. • Early discharge interfered with data collection process because some of the mothers that were observed, assessed by visual analog scale (VAS) and unstructured conversations were discharged before the in-depth interview would be conducted, so those mothers were not included in the sample. • Only one tertiary hospital of the Limpopo Province was involved in this research. The research findings are contextualised at this one hospital in Capricorn district.
152
7.6
RECOMMENDATIONS OF THE STUDY
On the basis of the results there is a need to develop the model and strategies and formulate the criteria that would encourage participation and collaboration so that attending midwives can enhance the self-determination of mothers during childbirth. It is recommended that the application of the model would be in maternity/obstetric and neonatal units, general nursing science and nursing research units, and at any institution where there is interaction between a mother (patient) and the attending midwife (nurse).
7.6.1 Recommendations for Implementation in Obstetric Units It is a special challenge for those involved in the obstetric units to improve their practices so that mothers who were less participative, as was the case in this study, may be able to participate more fully in the future. Since mothers experienced limited mutual participation and dependency during childbirth, the model and strategies could serve as a frame of reference to enhance mutual participation and responsibility sharing, information sharing and empowering and interdependence during childbirth in the tertiary hospital at the Capricorn district, Limpopo Province. The model would enhance the putting of the Batho-Pele Principles firmly into midwifery practice. The utilization of the criteria for woman-centered care as an institutional self-evaluation tool to enhance the implementation of the Batho-Pele Principles would encouraged. The researcher would be ready to discuss and share the guidelines for implementing the formulated criteria and the model as described in the strategies of implementing the model.
7.6.2 Recommendations for Implementation in General Nursing Units Limited participation and dependency may be experienced in all general wards in the hospitals wherever the patient is involved in the interaction with the nurse. As
153
stated earlier, to be in line with the ‘White Paper on Transforming the Public Service Delivery (1997), Patient Charter and the Constitution of the Republic of South Africa (1996), it would be recommended that the model be implemented at in general wards as well. The model is aimed at enhancing the provision of womancentered care which would facilitate mutual participation and responsibility sharing, creation of opportunities for information sharing and empowering, open communication and listening, accommodative midwifery actions and maximizing of human and material infrastructure during childbirth.
7.6.3 Recommendations for Implementation in Nursing Research Units The recommendations for research that would enhance mutual participation and interdependence collaboration during childbirth are vast topics that need further study in the Limpopo Province. The research study identified the following as elements that facilitate woman-centered care during childbirth: • Mutual participation - egalitarian and respectful relationship. Equality which includes the principle of power sharing and responsibility; there should be negotiation between the mother and the midwife. • Sufficient information that should be provided and which is thought to be prerequisite for decision-making is limited. • Interaction that takes place between the mother and a midwife should enhance the self-esteem and self-determination of the mother. The midwife and the mother should listen to each other because they engage in a dialogue to identify preferences and expectations and a new strategy for change is constructed. • Cultural experiences of a specific mother during childbirth need to be considered. • The need to pay attention to interaction skills by which participation can be enhanced and to study the practice of attending midwives in order to identify
154
their participation enhancing or lessening practices. Each of the above may be the research topic in itself. Subsequent research on experiences during childbirth could be replicated in other hospitals of all the districts in the Limpopo Province. Such endeavours could address the strategies of enhancing mutual participation during childbirth. The implementation of the woman-centered childbirth model as integrated within BathoPele Principles could be evaluated for its effectiveness using the formulated criteria. The hypothesis was formulated and could be tested in replicated (follow-up) research. This hypothesis could be: mutual participation and responsibility sharing during childbirth can be enhanced by the provision of woman-centered care.
7.6.4 Recommendations for Implementation in Neonatal/Maternity Units Limited mutual participation and dependency could be found in almost all the wards where there is interaction between midwife (neonatal nurse) and a mother. It is recommended that the Unit Managers in these units study this model to see if they can implement it, with the aim of enhancing mutual participation and responsibility sharing. It is also recommended that they test the effectiveness of the formulated criteria.
7.6.5 Recommendations for Implementation by the Department of Health, Maternal, Child and Woman’s Health Directorate in Limpopo Province The results of this research, with the developed model and criteria will be made available to the Directors at Maternal, Child, and Woman’s Health Directorate, Limpopo Province, for them to study the model and to see if they could implement it within the Department of Health, Limpopo Province. The model and criteria could be implemented in order to improve communication and enhance mutual participation and responsibility sharing, information sharing and empowering, increased decision-making and informed choices making capacity during childbirth.
155
7.7
SUMMARY
This chapter has assisted the researcher to review if the objectives and purpose of the research have been met. The developed model and strategies have been validated for applicability to midwifery practice. Limitations of the research study have been highlighted and recommendations were made for the implementation of the model and strategies in Obstetric, General Nursing, Nursing Research, Neonatal and Maternity and Maternal, Child and Woman’s Health Directorate in Limpopo Province. The recommendations of this study can be used in the basic and continuing education of midwifery as well as other health professionals sensitive to the value of woman-centered care provision.
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ADDENDUM 1 (A) UNIVERSITY OF THE NORTH NURSING PROGRAMME PRIVATE BAG X1106 SOVENGA 0727
THE SUPERINTENDENT GENERAL DEPARTMENT OF HEALTH & WELFARE P/BAG X 9316 POLOKWANE 0700 04 APRIL 2003 ATTENTION: Mrs S. MAHLANGU REQUISTION FOR PERMISSION TO CONDUCT THE STUDY IN THE HEALTH FACILITY Dear Sir/ Madam I am Maria Sonto Maputle, a doctoral student at Rand Afrikaans University in Johannesburg. I hereby request permission to conduct a research study in the health facility (tertiary), Mankweng Hospital. The title of my research project is: The experiences of childbirth by mothers and their attending midwives in the tertiary hospital, Capricorn district of the Limpopo Province.
The study will be conducted in your health facility, Mankweng Hospital, in the obstetrical and postnatal units.
The objectives of the study are to: •
Identify and describe the experiences of childbirth by mothers and their attending midwives.
•
Describe the management of childbirth process by the attending midwives.
167 •
Formulate the criteria for woman-centred care that will be utilized as an institutional self-evaluation tool to enhance the implementation of the Batho-Pele Principles in childbirth units.
•
Develop a woman-centred childbirth model that will be utilised by the attending midwives to enhance the facilitation of mutual participation during childbirth.
To complete the study, the researcher needs to collect data through participant observation during labour, and to carry out interviews with mothers within 24 hours of delivery in the postnatal ward. Interviews will be conducted with the attending midwives within 24 hours after conducting the delivery. The collection of data will not interfere with the ward activities and will not add work to the staff in the ward.
The prospective participants for the study are mothers and midwives who meet the following criteria: •
All mothers with term pregnancy (38-42 weeks), to be in early stage of labour (cervical dilatation of 3-5 cm with regular uterine contractions), with the presence of fetal heart beat.
•
Attending midwives who have at least one-year experience in labour ward.
The researcher will conduct interview for ±45minutes to 1 hour to mothers and ±30-45 minutes to midwives, to explore their experiences on childbirth. These interviews will be audiotaped and transcribed verbatim. The findings will be coded by the researcher and a co-coder. The researcher will ensure anonymity of respondents and of the health facility by allocating of fictitious names to each instead of using real names. Erasing the taped information on completion of the transcription by the researcher will ensure confidentiality.
The immediate and the long-term benefits of the study will be to allow a mother to indicate her options that reflect her philosophy and attitude towards childbirth and of making informed decisions. A woman-centred care model will be developed that will also be imed at improving the maternity care and student training by enhancing mothers’ involvement and participation in their care. The research findings will be made available to your office.
168 Attached find the following: •
A copy of the research proposal
•
A sample of a consent form for participants
I trust that my application will receive your favourable consideration.
Yours Sincerely
____________________ Ms Maria Sonto Maputle
My contact details are as follows: Physical Address: 72 Unit C Mankweng SOVENGA 0727 Work Address: Nursing Programme –University of the North Private Bag X1106 SOVENGA 0727 Telephone: Work (015) 268-2840 Home (015) 267-7480 Cell 084 602 2063 Fax: (015) 268-3080
169
ADDENDUM 1 (B)
170
ADDENDUM 2 (A) INFORMED CONSENT FORM FOR MOTHERS
My name is Maria Sonto Maputle, from the Nursing Programme, School of Health Sciences, University of the North. I am a doctoral student at Rand Afrikaans University at Johannesburg and am conducting interviews as part of a research project entitled “The experiences of childbirth by mothers and their attending midwives in the Capricorn district of the Limpopo Province”.
The purpose of the study is to talk to people like you about their experiences of childbirth in order to formulate the criteria of evaluating your care and to develop a woman-centred care model from the findings. The model will have guidelines that are aimed at allowing you to indicate your birth options to midwives and will also enable you to make informed decisions during childbirth.
As far as I can tell, there should be no risks or discomfort to you in sharing your experiences. Your participation will mean that I will visit you in the postnatal ward within 24 hours after you have delivered your baby, for an interview that will last not more that one-hour. During our discussion I will be taking notes to keep track of what has been covered. To get every word on paper I will record (audio-tape) our discussion. The recording is only to help me to remember what has been said. As soon as the tape has been transcribed, what you said will be erased so that no one knows who said what. Please also note that your name or any information that identifies you will not appear on the tape or on transcripts. Your identity will not be revealed when the study is reported or published. If you have any questions about the study or about participating in the study, please feel free to ask me (Sonto Maputle). You may call me at (015) 267-7480(H) or (015) 2682840(W).
171 Your participation in this study is totally voluntary. You are therefore under no obligation to participate. You have the right to withdraw at any time if you care to, without repercussion or penalty. I _____________________________ have discussed the above points with the participant. It is my opinion that the participant understands the risks, benefits and obligations involved in participating in this project.
________________________________
_____________
SIGNATURE OF THE INTERVIEWER
DATE
I______________________________________ understand that my participation is voluntary and that I may refuse to participate or withdraw my consent and stop taking part at any time without penalty.
I hereby freely consent to take part in this research project.
____________________________
_____________
SIGNATURE OF PARTICIPANT
DATE
172
ADDENDUM 2 (B) INFORMED CONSENT FORM FOR ATTENDING MIDWIVES
My name is Maria Sonto Maputle, from the Nursing Programme, School of Health Sciences at the University of the North. I am a doctoral student at Rand Afrikaans University in Johannesburg and am conducting interviews as part of a research project entitled “The experiences of childbirth by mothers and their attending midwives in the Capricorn district of the Limpopo Province.”
The purpose of the study is to talk to people like you about their experiences of managing mothers during childbirth in order to formulate the criteria that will be utilized as an institutional self-evaluation tool to enhance the implementation of Batho-Pele Principles and to develop a woman-centred childbirth model from the findings. The model will assist you in the enhancement of facilitation of mutual participation in childbirth units.
As far as I can tell, there should be no risks or discomfort to you in sharing your experiences. Your participation will mean that I will visit you in the labour ward within 24 hours after you have conducted the delivery, for an interview that will last not more that 45 minutes. During our discussion I will be taking notes to keep track of what has been covered. To get every word on paper I will record (audio-tape) our discussion. The recording is only to help me to remember what has been said. As soon as the tape has been transcribed, what you said will be erased so that no one knows who said what. Please also note that your name or any information that identifies you will not appear on the tape or on transcripts. Your identity will not be revealed when the study is reported or published. If you have any questions about the study or about participating in the study, please feel free to ask me (Sonto Maputle). You may call me at (015) 267-7480(H) or (015) 2682840(W).
173 Your participation in this study is totally voluntary. You are therefore under no obligation to participate. You have the right to withdraw at any time if you care to, without repercussion or penalty. I ______________________________ have discussed the above points with the participant. It is my opinion that the participant understands the risks, benefits and obligations involved in participating in this project.
________________________________
___________
SIGNATURE OF THE INTERVIEWER
DATE
I ______________________________________ understand that my participation is voluntary and that I may refuse to participate or withdraw my consent and stop taking part at any time without penalty.
I hereby freely consent to take part in this research project.
____________________________
_____________
SIGNATURE OF PARTICIPANT
DATE
174
ADDENDUM 3 BIOGRAPHICAL DATA AND TRANSCRIPTS FOR MOTHERS
BIOGRAPHICAL DATA 1.
Age in Years at Your Last Birthday 12-16 17-21 22-26 27-31 32-36 37±
2.
Gravity 1 2-3 4-5 >6
3.
Parity 2-3 4-5 >6
4.
Delivery Outcome (Exclude 2 Foetal Deaths) Normal Vaginal Delivery
175 Forceps or Vacuum Extraction Delivery Caesarean Section 5.
Duration of Labour 2-4 Hours 5-8 Hours >9 Hours
6.
Pain Relief During Childbirth Pharmacological Non-Pharmacological
7.
Cultural/Ethnic Group Northern Sotho Tsonga Venda Zulu Tswana Swazi Asian Whites Others
8.
Family Status Married Single Divorced Widow
9.
Religious Affiliation
176 Luthern Dutch Reformed Church (NG) Zion Christian Church (ZCC) Apostolic Church Others 10.
Educational Level Never Literate Primary School Literate Secondary School Literate Tertiary Institution
11.
Companion Present Yes No
12.
Participation in Childbirth Preparation Classes Yes No
Key: I - Interviewer P – Participant
Miss A ¹ I:
Good morning, how are you?
P:
I am fine thank you.
I:
Although I believe you know me (my name), my name is Sonto Maputle. I’m conducting a research on the ‘Experiences of childbirth by mothers and their attending midwives in the Capricorn district of the Limpopo Province’. I
177 already know your name, for the purpose of confidentiality and anonymity can I call you Miss A¹. I hope you don’t mind? P:
Yes I don’t mind, it’s OK, I understand.
I:
Can I also indicate that the information obtained will be kept confidential, will be used to improve the midwifery care by formulating the criteria and model and thereafter it will be destroyed.
P:
OK.
I:
Thank you very much Miss A¹ ‘Could you please describe/tell me about your experiences of childbirth in this hospital. Can I indicate that there is no right or wrong answers? I would like you to share with me your experiences of childbirth in this hospital.
P:
(Quiet)
I:
OK Miss A¹, How did you experience childbirth in this hospital? Did you perhaps have any specific preferences, needs or choices during childbirth?
P:
You know, I don’t know because it was the first time and I didn’t know what could I prefer or not and whether I’m supposed to indicate my preferences, but … What I can say is that, childbirth is very painful and nothing can be done to relieve the pain.
I:
OK, because you are saying it was the first time, you didn’t know what to prefer or not … ‘Can you please tell me, what would you prefer if you knew that you can indicate your preferences?
P:
Hmm … eh… I didn’t prefer/choose anything because I was not informed that I could be able to choose.
I:
OK, I see, but how would you prefer to be treated if you were informed?
178 P:
I would want to be with the midwife throughout the childbirth process, so that she can examine me, not to leave me alone because I was afraid to deliver alone and when the midwife is with me, she will tell me what to do.
I:
OK, were you free to communicate to your attending midwife that you want her to be with you throughout the childbirth?
P:
No, she was very busy but she was examining me when I reported/requested help.
I:
Earlier you indicated that you are afraid to deliver alone or you want to be with a midwife throughout the childbirth process. What’s your opinion with regard to the presence of a companion?
P:
You … mean a person from home?
I:
Yes … the one who is chosen by you and who is very close to you.
P:
I … hmm … didn’t know that I could bring someone, but (laughing) … no, I prefer a midwife only, no other person from home when I deliver a baby.
I:
Are you perhaps having a reason for not wanting any person from home?
P:
Yes, because, I would be safe when I’m with the midwife, midwives know their work and they would tell me what to do.
I:
OK … they tell you what to do … did you sometimes tell them what to do on you/ for you or how you preferred them to treat you during childbirth?
P:
No, they know their work because they are trained, and they know exactly what is happening, they are able to detect complications or prevent their occurrences.
I:
I see … is there anything that you would like to share with me regarding decisions that you had during your childbirth?
P:
No, I was not deciding, nurses were helping me, as they know.
I:
OK, I see … How were you expressing that you are feeling severe pain to get the attention of a midwife during childbirth?
179 P:
I was just keeping quiet and waited for the midwife to come and examine me. My mother told me to keep quiet because delivering the baby will relieve childbirth pain; nothing can be done to relieve it, I must pretend as if I don’t feel pain, but I must communicate to the midwife who will reassure me with soothing phrases.
I:
OK … without soothing phrases from the midwife, what were your expectations from them with regard to pain relief?
P:
(Laughing) … As I stated that nothing can be done, even in the Bible it was indicated that the woman will experience pain during childbirth.
I:
Is there anything else that you would like to share with me, concerning your experiences of childbirth or your preferences?
P:
Nothing, Oh I said that I expected the midwife to be with me throughout childbirth. Hmm … Oh, I don’t know as I indicated earlier that because it’s the first time, but I think if midwives can avail themselves of mothers throughout labour. To give detailed information to mothers on what to expect and do, I think this will give power to the mother to participate in her own care. Lastly, to examine me and to give feedback on my progress as this will allay my anxiety.
I:
Ok, by the way you mentioned that it was the first-time. Is there anything else that you would like to share with me?
P:
(Laughing) … nothing, except that I felt relaxed during childbirth because my parents reported to the ancestors (ba phasa) when I left home that I’m going to deliver, so I knew that we are protected (myself and my baby).
I:
Thank you very much Miss A¹, I appreciate that you have volunteered to participate in this study. I would like to briefly recap on what we have discussed so that you tell me whether they are true reflections of what you said. I asked you about your experiences of childbirth in this hospital. You told me that you didn’t indicate your
180 specific preferences/needs or choices because you didn’t know that you can do that and it was you first time (childbirth). You further indicated that you would prefer to be with the midwife (not companion) throughout the childbirth since midwives possess scientific knowledge of childbirth and they will reassure you with soothing phrases.
You stated that you were not expressing to midwives that you are
experiencing severe pain. Lastly, you stated that to shape midwifery care to suit your preferences, if midwives can give detailed information on what to expect during childbirth as this may relieve anxiety. P:
Yes, this is what I said.
I:
Thank you.
181
ADDENDUM 4 BIOGRAPHICAL DATA AND TRANSCRIPTS FOR THE ATTENDING MIDWIVES
BIOGRAPHICAL DATA 1.
Gender Male Female
2.
Qualifications Registered Nurse Midwife Advanced Nurse Midwife
3.
Duration of Allocation in the Labour Ward (Years) 2-4 5-6 >7
4.
Ethnic Group Northern Sotho Tsonga Venda Other (specify)
5.
Religious Affiliation Lutheran Dutch Reformed Church
182 Zion Christian Church (ZCC) Other (Specify), e.g. Pentecostal Holiness Church
Key: I - Interviewer P – Participant
Miss A I:
Good morning, how are you?
P:
I am fine thank you.
I:
Although I believe you know me (my name), my name is Sonto Maputle. I’m conducting a research on the “Experiences of childbirth by mothers and their attending midwives in the Capricorn district of the Limpopo Province”. I already know your name, for the purpose of confidentiality and anonymity can I call you Miss A; I hope you don’t mind?
P:
Yes I don’t mind, it’s OK, I understand.
I:
Can I also indicate that the information obtained will be kept confidential and will be used to improve the midwifery by formulating criteria for woman-centered care and developing the model and thereafter it will be destroyed?
P:
OK.
I:
Thank you very much Miss A “Could you please describe/tell me your experiences of managing mothers during childbirth in this hospital”? Can I indicate that there is no right or wrong answers? I would like you to share with me your experiences of managing mothers during childbirth.
P:
OK … (Laughing) when mothers are admitted in the labour ward – they don’t have any specific childbirth preferences that they verbalize, they listen to all what the midwife tell them to do.
183 I:
OK, even if they don’t have specific preferences – what are your experiences of management with whatever needs/demands.
P:
OK! Most of them look confused on admission, they don’t listen carefully like when requested to undress, they leave some of the clothes on. The primigravida mothers look very anxious while the multiparous mothers are very uncooperative, they compare the current pregnancy with the previous one, for example, they will say ‘the previous pregnancy had no problems, but this present pregnancy I’m suffering from pre-eclampsia’. Some would like/choose to deliver on the floor adopting a squatting position and would tell me that this is how they deliver at home. They are unwilling to follow instructions and to take treatment, may even refuse to be examined per vaginally, but those with information about childbirth issues, they cooperate.
I:
Thank you. It might be a challenging situation you are faced with, and then when you were in such a situation, how do you handle it?
P:
Hmm … it’s difficult here in the hospital (to allow a patient on the floor) and especially if that position is contra- indicated. But if she is not having problems, the position is allowed on the bed but not on the floor.
I:
Is there a problem if the mother prefers to deliver on the floor?
P:
Yes, it will be difficult to manage the delivery.
I:
OK, I heard you mentioning that mothers with information cooperate during childbirth. Which information about childbirth issues do those mothers possess?
P:
Information like what to expect and how to behave during childbirth.
I:
Thank you: Do you have specific expectations from the mother during childbirth?
P:
Yes, the mothers are expected to know what is to be done during childbirth, like undressing and that per vaginal examination is going to be done two hourly or four
184 hourly to monitor progress of labour. I expect the mother not to push with each and every contraction before the cervix is fully dilated and I expect the mother to open the legs when she is about to deliver. The mother must know that I’m going to inject her some medications during childbirth and lastly I expect the mother to listen and follow instructions as given. Some mothers will scream and when the midwife tries to explain the importance, for example, of breathing [nonpharmacologic] they don’t understand. Some are pushing with every contraction as long as they are feeling pain and not yet fully dilated. Primigravidas are difficult to progress, you’ll find that she closes her thighs during vaginal examination refusing to be assessed. Some will adopt the squatting style used at home during delivery. I:
You indicated a lot of mothers’ preferences; do you consider/accommodate those preferences during childbirth?
P:
Yes, some, for example, some cultural preferences are considered if a mother got some treatment from home that she want to use during labour like holy water, I do allow them to utilize as long as it is not toxic to her and the baby.
I:
Ok … hmmm … Do you perhaps have some reservations with allowing the mother to adopt the squatting position during childbirth?
P:
Yes, because this position if adopted made mothers to be susceptible to sustain third degree tears.
I:
Ok, are there other preferences that you considered during childbirth?
P:
Yes, some mothers come in the ward with threads tied on their waist for their protection purpose and those are not removed, but will only be removed when the mother is taken to the operating theatre. The other issue that I don’t accommodate if, the mother will say she wants her membranes to be ruptured so that she can deliver quickly.
185 I:
Oh … now does it mean that you discourage mothers to take part in their care as you indicated by ROM?
P:
No, we do allow their decisions, but membranes are kept intact as possible during labour.
I:
Is there anything else pertaining to the experiences of managing mothers’ childbirth that you would like to share with me?
P:
Yes, mothers put themselves into the hands of midwives and keep on saying, ‘you know best, I don’t know so much’. I think they are just very compliant. I think they must take part in their care.
I:
OK… Do you involve mothers in decision-making or encourage them to take control of their care during childbirth?
P:
Yes, I do encourage involvement, but most of the times mothers will tell you that assist and help me because you are an expert, anything that you do is OK as long as I deliver the healthy baby. Again the friendly welcoming and explanation of all the procedures done on her I think that will promote her involvement for her to come up with her preferences. Mothers are also allowed to give feedback of care and the clarifications are given.
I:
Thank you very much Miss A: I appreciate you having volunteered to participate in this study. I would just briefly recap what you have been telling me since we started. I asked about your experiences of managing mothers during childbirth and you told me that mothers were not verbalizing any specific childbirth preferences during childbirth. Mothers with little information regarding childbirth issues don’t cooperate as compared to those with information. You enlisted all your expectations from mothers during childbirth. You do accommodate mothers’ preferences/choices as long as they are harmless to mother and baby. You do
186 encourage the involvement of mother in the childbirth care but mother prefer the passive role. Did I understand you correctly? P:
Yes, thats correct.
I:
Thank you.
187
ADDENDUM 5 SEMI-STRUCTURED PARTICIPANT OBSERVATION GUIDE
PARTICIPANT (S) : ______________________ DATE AND TIME : ______________________
Observations will be done during the active phase of labour (cervical dilatation of 3 cm with regular contractions) until the end of the third stage of labour is complete.
This guide will be used to observe the following throughout the childbirth process: •
Actors (mothers and attending midwives)
•
Activities/events (interaction between mother and attending midwife during childbirth:
•
Setting (in the labour ward)
•
Context (during childbirth)
Interaction Between Mother and Attending Midwife During Childbirth •
Communication o Midwife able to empower mother during labour o Enable her to feel special and relaxed o Be a mother’s advocate when with the doctor o Determine from mother her cultural/personal preferences o Continuous monitoring of maternal and fetal condition and up-date the mother on progress of labour.
188 •
Informational Support o Answer all questions and allow mother to ask questions without feeling that she bothers the midwife o Advise of things prior to the occurrences in a normal progress o Offer mothers an opportunity to make suggestions o Give advices and encouragements o Guide the mother throughout childbirth process and assist with delivery .
Midwifery Care When Mother Is Responding To Pain •
Emotional Support Activities During Childbirth o Instil confidence to mother by encouraging the presence of companion to help mother through pain, o Be understanding, friendly and reassuring to the mother o Encourage free choice on activity, and encouragement of full participation throughout childbirth o Encourage the integration of cultural/ personal preferences in the midwifery care Show respect
•
Supportive Care Activities During o Provision of physical comfort measures, for example, touch and assisting by fulfilling specific request o Attendance of elimination needs o Midwife care for more than one mother at the same time
189
ADDENDUM 6 VISUAL ANALOG SCALE (VAS) = 100mm
PARTICIPANT
: ________________________
CERVICAL DILATATION
: ________________________
DATE
: ________________________
TIME
: ________________________
The Visual Analog Scale (VAS) will be given to mothers and their attending midwives with the aim of comparing the childbirth pain experienced among mothers and the pain exhibited by midwives.
A mother and her attending midwife will complete the scale independently during the following phases of cervical dilatation: •
0-3 cm
•
4-7 cm
•
>8 cm
All assessments will be completed without reference to the previous rating.
INSTRUCTION Kindly place a mark through the line to indicate the intensity of the painful stimuli. Example of VAS:
This information will assist in determining the physical comforting measures rendered by the attending midwife when the mother is responding to childbirth pain.
190
ADDENDUM 7 A GUIDE TO VALIDATE WHETHER THE MODEL CAN BE APPLIED TO PRACTICE
A. Theory Goal and Practice Goal Relationship Criterion 1.
Yes
No
Suggestions
Yes
No
Suggestions
No
Suggestions
Is/does the goal of this model judged to be of value in nursing practice?
2.
Is the theoretical goal of the model consistent with the goal of optimal health?
3.
Is
operational
validity
ensured so that the model output has enough accuracy for its intended purpose? B. Situational Factors Criterion 1.
Is the model congruent with the situation where it will be applied?
C. Theory Variables and Practice Variables Criterion 1.
Does the model describe the phenomenon under study?
Yes
191 (woman-centered care)
2.
Are
practice
variables
included in the theoretical relationship statements? D. Nursing Actions Criterion 1.
Yes
No
Suggestions
Yes
No
Suggestions
Does the relationship within the model provide sufficient explanation to provide a basis
for
planning
and
implementation
of
midwifery actions?
2.
Does the model provide explanation
for
phenomenon centered
the
(womancare)
and
predictions of the outcome?
3.
Does the model provide direction for nursing actions needed?
E. Research Evidence Criterion 1.
Does the model provide research evidence to support the theoretical formation?
192 2.
Is the research evidence sufficient to justify this model in practice?
193
ADDENDUM 8 GUIDE TO VALIDATE WHETHER THE STRATEGIES CAN BE IMPLEMENTED IN THE CLINICAL PRACTICE
Strategy 1 Facilitate Mutual Participation and Responsibility Sharing by Integrating Batho-Pele Principles During Childbirth. Criterion 1.
Does the strategy enhance the provision of woman-centered care?
2.
Are the Batho-Pele Principles appropriately integrated in this strategy?
3.
Are there gaps and inconsistencies in the implementation of this strategy?
Yes
No
Suggestions
Strategy 2 Sharing/Exchanging of Information and Empowering by Integrating the Batho-Pele Principles During Childbirth Criterion 1.
Does the strategy enhance the provision of woman-centered care?
2.
Are the Batho-Pele Principles appropriately integrated in this strategy?
Yes
No
Suggestions
194 3.
Are there gaps and inconsistencies in the implementation of this strategy?
Strategy 3 Enhancing Open Communication and Listening by Integrating the Batho-Pele Principles During Childbirth. Criterion 1.
Does the strategy enhance the provision of woman-centered care?
2.
Are the Batho-Pele Principles appropriately integrated in this strategy?
3.
Are there gaps and inconsistencies in the implementation of this strategy?
Yes
No
Suggestions
Strategy 4 Accommodate Mother’s Choices and Preferences by Integrating the Batho-Pele Principles During Childbirth. Criterion 1.
Does the strategy enhance the provision of woman-centered care?
2.
Are the Batho-Pele Principles appropriately integrated in this strategy?
3.
Are there gaps and inconsistencies in the implementation of this strategy?
Yes
No
Suggestions
195 Strategy 5 Maximize the Human and Material Infrastructure by Integrating Batho-Pele Principles During Childbirth Criterion 1.
Does the strategy enhance the provision of woman-centered care?
2.
Are the Batho-Pele Principles appropriately integrated in this strategy?
3.
Are there gaps and inconsistencies in the implementation of this strategy?
Yes
No
Suggestions
196
ADDENDUM 9
197
ADDENDUM 10
