First-time New Zealand mothers' experience of birth: importance of relationship and support.

INTRODUCTION

A significant change occurs when a woman becomes pregnant and gives birth to a baby (Fowles & Horowitz, 2006; Howarth, Swain, & Treharne, 2010; Mercer, 2004). New mothers' self-concepts undergo radical changes in order to incorporate this new role, the 'maternal identity', into an already established sense of self (Rogan, Shmied, Barclay, Everitt, & Wyllie, 1997; Rubin, 1984). One of the issues that affect a woman's sense of herself as a competent mother is the extent of her satisfaction with her birthing experience (Bradley, 1996; Klaus, 1998; Rubin, 1984; van Teijlingen, Hundley, Rennie, Graham, & Fitzmaurice, 2003). Indeed, "it is the birth that provides a crucial turning point" (Miller, 2002, p. 17).

Research has established that a negative birthing experience can affect a mother's early interaction with her infant (Koniak-Griffin, 1993; Waldenstrom, Hildingsson, Rubertsson, & Radestad, 2004). The new mother may be left experiencing a lack of control. She may feel bewildered by the realisation of changes to her lifestyle, and thus have difficulty establishing her maternal identity (Miller, 2002). This has potential long term psychosocial implications since a mother's sense of maternal identity has the capacity to either facilitate or impede her ability to develop a secure attachment with her infant (Nelson, 2004).

It is therefore crucially important that birth satisfaction is considered for every woman giving birth. One factor contributing towards birth satisfaction is experiencing personal and caring support (Common Knowledge Trust [CKT], 2001; Koniak-Griffin, 1993; Rubin, 1984; van Teijlingen et al., 2003). Using self-report data from women at a mean 24 weeks gestation, Glazier, Elgar, Goel, and Holzapfel (2004) confirmed that good social support predicted positive consequences for both the birthing process and later as the woman adjusted to her new role as mother. Similarly, the women in studies conducted by Halldorsdottir and Karlsdottir (1996) and Gibbins and Thomson (2001) expressed a strong need for understanding and caring from those who were a part of their birth journeys. Positive social support from midwives, partners and significant others assisted women to cope with the changes and challenges experienced throughout their pregnancies and birthing processes. Howarth, Swain and Treharne (2011) reported that taking personal responsibility to be well-informed and well-prepared also had a positive impact on birth satisfaction for New Zealand women.

Of particular importance is continuous support throughout the birthing process (Hodnett, Gates, Hofmeyr, & Sakala, 2005). For example, a consistent finding is that such continuous one-to-one support can reduce a woman's perception of pain and hence her need for analgesia (ibid). While a midwife may offer this continuous support once labour is well established (Vincent, 2008), an expectant woman relies on others for continuous support from the first twinges that indicate the commencement of labour (Bradley, 1996; CKT, 2001). Bradley (1996) felt the father of the child was most qualified to do this because of the emotional connection he usually has with the mother.

The father's continuous presence has been found to increase his partner's feeling of satisfaction with her birthing process. Icelandic women described their vulnerability while in labour and their need for support and caring from those close to them in words such as "He didn't have to do anything or say anything, just that he was present ... that he was there to experience this with me. That was extremely important" (Jean, 33, mother of four, Halldorsdottir & Karlsdottir, 1996, p.54). Gungor and Beji (2007) established that Turkish women felt supported and better able to cope when each was encouraged and reassured by her partner; when her partner tried to understand and showed his love for her; when he was able to communicate well with her; when he facilitated decisionmaking between her and medical personnel; and when his support made her feel she was not alone. Such continuous one-to-one support during labour and birth contributed towards a woman's sense of birth satisfaction thus positively introducing her into the role of motherhood.

In a review of relevant literature, Howarth, Swain, and Treharne (2010) identified a lack of studies examining the New Zealand birth experience. As it could not be assumed that issues related to social support throughout pregnancy and birth and continuous support throughout labour and birth identified in other cultures would automatically reflect New Zealand birthing traditions and concerns, an interpretive phenomenological approach was used to examine the birthing experiences of first-time mothers in New Zealand (Smith, 1995). Traditional hypotheses were precluded, as the data themselves shaped how the research question was answered (Braun & Clarke, 2006). The broad research question was: What issues are evident in the birthing experiences of first-time mothers in New Zealand, and how do they feel about these experiences in the months after birth? This article focuses on the ways in which relationship issues and support were raised as central to the New Zealand birthing experience of ten first-time mothers.

METHOD

Participants

The inclusion criteria were: 1) first-time mothers (with singleton pregnancies) who had given birth to a healthy baby within the 4 months prior to the interview; 2) being aged between 18 years and 42 years; 3) having been registered with and received care during pregnancy from a midwife; and 4) living with the father of the baby. Participants were sufficiently literate to be able to speak and read English to the level required by the study.

The ten participants were aged 24 to 38 years (mean/median age 31.5 years). The mean age for women giving birth to their first child in New Zealand was 28 years for the year ending March 2008 (Statistics New Zealand, 2008). Educationally, participants varied from school leavers who sought practical qualifications through to university graduates, with one participant holding a PhD degree. All participants had studied and/or worked before having their babies in a range of subjects and career options.

Procedure

Participants self-selected by contacting the interviewer (AH). A newspaper advertisement was placed in a local community newspaper. Posters were placed in areas frequented by new mothers and a snowballing technique was used. All interviews were face-to-face. Of the ten participants, seven elected to meet in their own homes, two elected to meet in the house of one of the researchers (NS), and one elected to meet at her place of work. Information sheets and study questions were emailed to participants prior to the interview.

Consent forms were completed prior to the commencement of the interviews at which time participants were asked if they had any questions or concerns. The interviews lasted between 57 minutes and 106 minutes (mean 76 minutes). Three interviews had two researchers present (AH with NS). Each participant was assigned a pseudonym and other identifying material was removed or altered to protect the anonymity of individuals and organizations. Participants were gifted a $20 petrol voucher for taking part in the study.

Ethical approval from the New Zealand Lower South Regional Ethics Committee was gained for this study reference number: LRS/08/22/EXP).

Data Analysis

A form of thematic analysis informed by Interpretative Phenomenological Analysis (IPA) (Smith, 1995, 1996; Smith, Flowers, & Larkin, 2009; Smith, Jarman, & Osborn, 1999) was used in order to obtain a more complete and detailed description of the experiences of birth encountered by the local women (Trochim, 2006) than a standard quantitative instrument was likely to provide (Reid, Flowers, & Larkin, 2005). This analysis is both descriptive and interpretive.

Once participants had confirmed the verbatim transcriptions of interviews accurately expressed their perceptions of their birth experiences, data analysis was commenced. Patterns within the qualitative data were identified using information coded across the data corpus (Braun & Clarke, 2006). Data were then organised into meaningful groups. Data from the transcript that supported each code were briefly summarized. This interview summary detailed the designated codes and supporting data in the order they arose in the interview. Next, to ensure each woman's experience of pregnancy, labour and birth had been accurately interpreted. A 'Birth Story' reflecting these individual interview summaries was written and sent to individual participants with a request for any feedback to be sent via email (their prefered method of communication).

Connections between the initial themes were identified and organised into broader themes across participants. Core themes were identified along with related sub-themes. It was found that some initial themes were more realistically sub-themes of larger themes, and thus a pattern of hierarchy became apparent. This process continued until the primary analyst (AH, with ongoing feedback from NS and GT) felt the themes provided a good overview of the data corpus and the relationships between the themes that were emerging. By the end of this phase, four core themes were identified and named. These consisted of: 1) taking personal responsibility; 2) relationship and support issues; 3) midwife and doctor relationships; and 4) safety net. This article will focus on four of the implications of relationship and support issues, namely: 1) midwife relationships; 2) partner involvement; 3) family and friend support; and 4) continuous support during labour and birth. In the following presentation of results, participants are referred to by their pseudonyms; editing is marked as [...] and additional clarifications within quotes are also noted in square brackets.

RESULTS

Birthing characteristics

Three babies were born at home; the remaining seven were born in hospital. All babies were vaginal births. Further details of participants' birth experiences can be found in Howarth, Swain and Treharne (in press).

RELATIONSHIP ISSUES

Relationship issues with those people who were involved with these participants' pregnancy, labour and birth support and care were described as being of great importance. 1) Midwife relationships; 2) partner involvement; 3) family and friend support; and 4) continuous support during labour and birth were four of the sub-themes identified in the core theme relationship issues.

The midwife relationship

Self-employed midwives were the Lead Maternity Carers (LMCs) for all participants. For some participants it was quite an issue finding the right midwife, in part owing to a shortage of midwives, particularly midwives who care for a particular cultural niche:

   So I, um, decided that I wanted a Maori
   midwife, so I rung round and there aren't
   really any in [town]. There's like one that I
   found listed and I rung her up and she said
   she was overbooked, too booked. (Ngaire)

While she was unable to find an available midwife from her own culture, Ngaire eventually engaged a midwife who came from a minority cultural background that Ngaire could relate to. Her midwife related to, and understood, Ngaire's cultural needs. The midwife was also able to demonstrate her professionalism to an extent that Ngaire's partner felt reassured that Ngaire would be safe to attempt a homebirth.

The trust women placed in their midwives gave them a sense of security and reassurance, and so the support from their midwives was very important, especially once labour really got going. Anita describes her distress when her midwife had to go to an appointment and leave her for a short time as her labour started to escalate:

   The last time she went away I felt a bit
   stressed out by it [...] coz she came in and
   sort of stopped and had her lunch and she
   had one more appointment to go and I felt
   like things were sorta escalating a little bit
   and she's like ... "It's 5 minutes down the
   road". [...] It was just like, you know, this
   woman really needs me, I need to get this
   one in, coz I think she might be going into
   labour. It was like "Okay, I can give you the
   half hour to go ". [...] But she was really good
   about why she was needing to go, but still
   I would have liked her to have stayed if she
   could. (Anita)

Participants in this study were looking for a close and personal relationship with their midwives in which they felt comfortable with each other:

   We just phoned [midwife's name][...] and
   just, you know, talked to her on the phone
   a few times before we met her, but we could
   feel right away, you know, she was really
   warm and friendly and lovely, without
   meeting her we knew she was the right
   person, you know, it just felt right. (Beth)

It was important to participants that their midwives demonstrated their understanding of the uniqueness of the pregnancy and birth experience for each woman and that they responded accordingly:

   Because she [her midwife] came in and, um,
   and washed me in the shower, which was
   really lovely and I didn't know I needed help
   and I'd never been washed by anyone else
   [laughs] in my life, you know, it was actually
   really lovely. [...] Um, you know, there was a
   lot of blood and [she] washed it all off. And
   I guess that was quite nice that, even though
   he was born, the focus didn't immediately all
   shift onto him, you know, [...] and that was
   quite a nice completion of the process for her
   to be there with me then. [...] Um, yeah, I
   felt very supported by her doing that. (Beth)

Midwives had encouraged participants to take personal responsibility for their own birthing processes and they guided without pushing:

   Yeah, yeah, really, yeah, really wise and very
   gentle as well and nice. [...] Yeah, yeah, yeah
   she was really good. Yeah, and also, um,
   quite respectful of our wishes and wants with
   different things, like she would often, she was
   slow to offer advice but very quick to offer
   sort of information or resources um, but with
   perhaps a heavy emphasis on us making the
   decision or us trusting our intuition, or um,
   or reading up and finding out, but she would,
   she would be there to offer information and
   I, I don't think she ever would've made a
   decision on our behalf. (Kim)

If medical intervention was required, women wanted their midwives, who were aware of their personal wishes and needs, to be knowledgeable about their situations and, if necessary, to advocate for them:

   She [her midwife] was very good at making
   it very clear to the doctors that we were, we
   had really wanted a home birth and that
   we were only there because things were going
   wrong, like, you know, she, she made that
   clear to them because she said, "If they know
   that, they're often more", um, "respectful of
   your wishes, [...] because you are, you're
   already out of the environment you wanted
   to be in". (Beth)

Partner inclusion and involvement

In talking about the importance of her partner's inclusion and involvement in her pregnancy care, labour and birth processes, Anita said:

   They're half the whole process [laughs] you
   know. (Anita)

Anita went on to explain how her husband came to her antenatal visits with the midwife. He was determined to be a part of this new journey their relationship was taking:

   My husband, came with me 99% of the
   time, um, cos he's a teacher so he's quite a
   curious beast [laughs]. [...] So he really
   wanted to know what was going on and
   he wanted to be able to ask the questions
   about what was happening for me as well.
   [...] [He] really was very determined to be
   involved with the process. (Anita)

When asked if her midwife made her partner welcome, Anita replied:

   Yes completely, yep. It was one of the provisos
   that I put on when I asked her if she wanted
   to be my midwife. I said my husband will
   be there a lot. He will ask lots of questions.
   (Anita)

Women felt the need of the closeness their relationships with their partners entailed, as well as the emotional and practical support. Partners offered this caring assistance in a number of ways:

   He'd come home and he'd cook and he'd clean
   and, yeah, he was just really good, [...] really
   helpful, ran me baths and all of that sort
   of thing. [Emotionally] he was really good.
   [...] We did freak out a wee bit when they
   were saying [baby's name]'s small and he's
   just saying, look, you know, it doesn't matter,
   she'll be alright, she's healthy, you know. We
   knew she was kicking and he just, he was
   very reassuring. (Rae)

All of the women in this study wanted and expected their partners to be present at the birth. Wendy, who was concerned her partner's career might see him out of town when she gave birth, remarked:

   I was very pleased to have him there, yeah, it
   was really good. [...] Oh, yeah, I would've
   been really gutted, I said, "I didn't know if
   I'd forgive him if he wasn't there". [...] Yeah,
   so he had to be, so I was very pleased he was
   there. (Wendy)

However, once the baby was born, not all new fathers took to baby care without some encouragement, because they felt they lacked the necessary skills:

   I didn't give him a choice. I think if I'd given
   him a choice he would've opted out and "I
   don't know what to do, so I wont." (Anita)

The women who took part in this study were aware that bringing a baby into their couplehood entailed changes for their partners as well as themselves. Their partners would also be facing major relationship and lifestyle changes along with new responsibilities. To ease the incorporation of a family relationship into an already established couple relationship, Anita aptly commented:

He needs to be part of this process. (Anita)

Several participants noted that it was stressful for both partners when hospital policy dictated the new father must leave the hospital at night after a birth, especially as in these cases, medical interventions had occurred. Both partners wanted to experience together those first hours in the new family relationship the birth of their child had created:

   It wasn't like, I mean he was just sort of
   sitting there and so was I, so it wasn't like he
   was being noisy or anything but, yeah, they
   said, "No, he had to [leave]". [...] I was
   actually quite upset. [...] I didn't want, I
   didn't want him to leave, I sort of thought
   he'd be with us the whole time. [...] I mean
   we hadn't really had much of a chance to
   talk, because I was being monitored and we
   always had other people in the room and I
   just would've like some time on my own with
   him. (Rae)

Partners took this journey together, recognising that each had needs to be met and working to meet those needs for each other:

   My partner and I were at pains to ensure
   that the early stages of labour were restful
   and fun! Seems funny to say it, but the first
   couple of hours were fun; very exciting for
   both of us. We put the music on and danced
   around the living room (well I waddled more
   than danced!). We both look back on that
   with fond memories! (Kim)

Family and other support people

Families and friends were also important providers of the social support participants desired so that they felt encouraged and cared for throughout their pregnancies:

   I don't have family around but his family's
   around and would do things, like always
   drop off lots of firewood and lots of friends
   who were interested in the pregnancy and
   supportive and wanting to talk about it and
   stuff like that. (Wendy)

Kim, whose family lives overseas, discussed the practical support she and her partner received from the community they were a part of:

   We had good support from when we lived in
   [suburb]. There's a lot of young families there
   and so we were on, um, yeah, a lot of friends
   came out and helped. (Kim)

This support continued after the birth of the child:

   Actually there's, between that friendship group,
   there's a roster of the domestic goddesses; so for
   the first 2 weeks, we had, um, evening meals
   dropped off, which was really nice, and that's
   been something that we've all done for each
   other [...] as the children come along. So we
   had 2 weeks of evening meals which was lovely.
   (Kim)

Continuous support throughout labour and birth

The participants in this study found continuous support during labour and birth to be an issue of importance. When it came to the birth, the participants had thought carefully about who they did and did not want to be present:

   My mother would not have been helpful.
   [...] I had a first year [midwifery] student
   follow me through [...] And she was great!
   [...] It was fabulous, especially on the day of
   the birth. [...] Because of course [husband's
   name] was sort of my main support person
   but of course he needs to pee and eat
   [laughs]. [...] And, and he needs a break.
   [...] As much as I can't stop what I'm doing;
   it's a escalating process that started and I
   can't stop it. He needs to stop and she was
   just incredible. She was so good. [...] I have
   some close friends that were sort of on that
   list of [...] extra people if we needed more
   people if people needed to sleep and rest and
   stuff. (Anita)

Anita had put a lot of energy into organising her home birth so that when her partner, whom she considered her main support person, needed to take a rest or have a meal or visit the toilet, there would always be someone there to hold her hand. When asked how important she felt it was to have a support person other than her husband and midwife for her home birth, Anita answered:

   Extremely important. I think, I think even if I
   had have been in the hospital I would've felt a
   bit lost without her. (Anita)

Cath also expressed the importance she put on having family members present to support her through labour and birth:

   They were, they were just, you know, every
   time one of them hold my hands. (Cath)

The women felt that having somebody always present was important. They were advocating for continuous support throughout their labour and birth process.

DISCUSSION

In the present study, participants agreed with previous New Zealand research (Ministry of Health, 2007) that a warm and caring relationship with professional maternity carers was desirable. Lack of satisfactory relationships contributed to a sense of vulnerability and associated anxiety. The present study also provides evidence for the ways in which first-time New Zealand mothers' birth satisfaction is affected by the social support received from partner, family and friends. Social support throughout pregnancy, and continuous support throughout labour and birth, were very important for these New Zealand mothers. The sense that they were not alone on the journey of birth enhanced the participants' belief in themselves and positively introduced them to motherhood.

Participants in the present study favoured the current New Zealand midwife-driven maternity system, also supporting previous research (ibid). However, unlike some women who completed the New Zealand Maternity Services Consumer Satisfaction Survey (ibid), all of the participants in the present study were able to register with a midwife. Some participants experienced initial difficulty finding a midwife suitable for their needs. For example, Ngaire was unable to register with the midwife who shared her Maori cultural background as this midwife was fully booked for the month. But even when women had registered with a suitable midwife, they had no guarantee that their familiar midwife would be available when they eventually went into labour.

In support of previous research (Halldorsdottir & Karlsdottir, 1996; Lundgren & Dahlberg, 2002; Ministry of Health, 2007), this study identified the importance the participant placed on her relationship with her midwife. Lundgren's and Dahlberg (2002) commented that "the quality of the relationship between the woman and the midwife is a key factor for good support during childbirth" (p. 155). The relationship a participant had with her midwife built over time, as the woman and her midwife came to know each other and trust developed. Having midwife continuity of care was important to participants. Each woman wanted to give birth at a time when her own midwife would be on call/available. Even if a woman required medical intervention she felt reassured if her midwife was present, especially when the midwife advocated for her.

Each participant wanted her midwife to demonstrate her understanding of the uniqueness of each birth and to individualise care given. Participants expected that their midwives had the capacity to work with pregnant and birthing women, supporting their birth desires in a realistic manner. The midwives who were most successful guided without dictating, and encouraged their clients to be proactive in managing their own labour and birth processes. Only Rae felt any disappointment in her midwife, largely owing to the midwife's lack of advocacy and lack of awareness of the trauma Rae had experienced during the medical intervention that became necessary. Despite this Rae still felt that she could work with this midwife again for a subsequent pregnancy, highlighting that situational factors and communication were pertinent. Issues between midwives and doctors which arose in this study are discussed elsewhere (Howarth, Swain and Treharne, in press). Overall, the relationship participants developed with their midwife had the potential to greatly enhance the satisfaction a woman experienced with her birth experience. For example, Beth talked about the warm sense of completion she experienced when her midwife washed her in the shower after she had given birth.

In particular, continuous support throughout labour and birth was an issue for all of the present participants. The importance of continuous support during labour and birth has been well documented since Sosa, Kennell, Klaus, Robertson, and Urrutia, (1980) paper on the topic (see also Howarth, Swain, & Treharne, 2010). Researchers such as Klaus (1998), Klaus and Kennell (1997), Hodnett (2005) and others have examined this concept thoroughly and supported Sosa et al.'s (1980) findings that continuous support gives comfort and enhances a woman's experience of birth. It has also been shown to decrease the length of and difficulty of labour, reducing the need for medical interventions (Sosa et al., 1980). The reports of the women in this study provide further evidence of the importance of continuous support.

As well as the support of midwives, all of the women in the present study wanted and expected their partners to be present during labour and at the birth. Participants found continuous emotional, physical and informational support from their partners added to the intimacy and specialness of the birth thus supporting work by Bradley (1996), Gungor and Beji (2007), and Halldorsdottir and Karlsdottir (1996).

Developing team skills was discussed as an important aspect of birth preparation for the pregnant woman and her partner. Both partners recognised that each partner was facing major lifestyle changes, and the father-to-be was encouraged to gain knowledge and skills to assist during labour and birth. Participants worked together to adjust to their changing relationships and lifestyles, moving from couple-hood to a family relationship. Participants made the point that parenthood was a new journey for their partners as well. A partner had needs to be addressed as new responsibilities were taken on board (Friedewald, Fletcher, & Fairbairn, 2005; Turan, Nalbant, Bulut, & Sahip, 2001). This supported findings by Friedewald (2007) who wrote about the need expressed by fathers to be a part of the process of giving birth to their child.

Concern was expressed by participants that there were few resources available for the soon-to-be father to help him adjust to his new role. For the present participants, being pregnant and giving birth was a family event and one in which their partners had major roles to play. This attitude reflects a change in the perceived role of the father which initially saw the father as the provider but now sees him as taking a more active part in childcare (Castle, Slade, Barranco-Wadlow, & Rogers, 2008). Participants felt that those partners, who had had no previous experience of infants, were concerned about their abilities to care for a newborn. This apprehension was supported in a study conducted by Castle et al. (2008). They also found that men were concerned about the transition from a couple to a family with a child (Castle et al., 2008). Boyce, Condon, Barton, and Corkindale (2007) concluded that providing men with more information regarding pregnancy, childbirth and parenting would be a positive step in assisting these men to overcome their anxieties, a step which present participants would support.

Participants in the present study also commented on how difficult partners found witnessing their labour pain, particularly when partners did not know what they could do to help. Chapman (2000) found that men tend to find it very difficult to cope with the pain the birthing mother may endure. He suggested that the father felt frustrated and helpless when his partner was experiencing difficulty in coping with labour pain. This finding is supported by Greenhalgh (2000) who found that how the father experiences his partner's labour and subsequent birth may actually affect his later psychosocial well-being. Vinnie and Rae described how their partners were distressed as a result of witnessing their difficult birth experiences. In the present study, for those partners who had witnessed difficult births, the local hospital policy which insisted new fathers leave even in the middle of the night after the birth, exacerbated this distress. This policy, imposed by the necessity of shared accommodation for mothers, also created distress for the new mothers, Vinnie and Rae. After a difficult birth they felt a great need to be close to their partners. The women were also aware of their partner's distress and were left feeling anxious about their partner's well-being at a time when their energies could have been better directed towards bonding with their baby.

Limitations of this research include that the project drew upon the birth stories of ten women who self-selected to participate, perhaps because they felt they had a story to tell or were seeking reassurance that their story was not out of the ordinary. The present study necessarily took a retrospective approach and it may be that in coming to terms with their experiences, some issues of potential importance were reevaluated by the participants. Also birth can be a difficult experience and several participants acknowledged that there were some areas of their birth experience about which they were unsure as their memories were not clear.

Despite the issues raised by a retrospective approach, the present study has a major strength in that the methodology allowed for a deep exploration of what these women experienced and how they perceived their experiences. The result is an interpretive and descriptive picture of what did and what did not work for these particular women. It cannot be assumed that all women giving birth will come from such backgrounds, nor that they will have the personal skills that these well educated New Zealand women had. As a result, it can be expected that there are many first-time mothers who will have had very different experiences of pregnancy, labour and birth that this study did not attract or reach. Also women who are giving birth for a second, third or later time may have different perspectives of the birth experience that merits further exploration in relation to the themes described in the present study. Future studies would benefit from recruitment methods that make them more attractive to other demographic groups, and might use a stratified approach for inclusion of a range of participants. Women who are younger, for example teenage mothers, and women who are older, for example women giving birth for the first time in their 40s, will have different stories to tell from which different themes may emerge.

While this report includes cases of women who had both satisfying home and hospital births, it does not include a homebirth that did not go as planned as a counterbalance to the hospital births that required intervention. It also does not include any women who required caesarean sections, or who had a baby with detrimental outcomes from complications, so another potentially important part of the broader picture requires further investigation.

It must also be remembered that these stories portray only one perspective, that of the woman giving birth. It may be that other stakeholders, such as the fathers, the midwives, both independent and hospital midwives, and others who comprise the maternity health professional teams, perceive their roles in quite different ways. Their perspectives on the births in this study, should they have been involved, could have been different to the perceptions of the births as described by the women themselves.

CONCLUSIONS

Positive relationships were important to the participants and contributed to an increased sense of satisfaction with their birthing process. The midwife relationship was extremely important to all participants. Continuous support was an expectation of these participants and was provided by family, friends, and midwives. Partners were considered the primary provider of continuous support. Participants wanted their partners involved in their pregnancies, labours and birth for the support partners gave and as an acknowledged part of the changes occurring in their relationships, from couple-hood to family. Acknowledging the importance of relationships and encouraging relationship development is likely to enhance the sense of birth satisfaction felt by New Zealand mothers.

Accepted for publication: August 2011

REFERENCES

Boyce, P., Condon, J., Barton, J., & Corkindale, C. (2007). First-time fathers' study: psychological distress in expectant fathers during pregnancy. Australian and New Zealand Journal of Psychiatry, 41, 718-725.

Bradley, R. A. (1996). Husband-coached childbirth. Bantam Books: New York.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101.

Castle, H., Slade, P., Barranco-Wadlow, M., & Rogers, M. (2008). Attitudes to emotional expression, social support and postnatal adjustment in new parents. Journal of Reproductive and Infant Psychology, 26, 180-194.

Chapman, L. L. (2000). Expectant fathers and labor epidurals. The American Journal of Maternal Child Nursing, 25, 133-138.

Common Knowledge Trust [CKT]. (2001). The pink kit. Nelson: Anchor Press.

Fowles, E. R., & Horowitz, J. A. (2006). Clinical assessment of mothering during infancy. Journal of Obstetric, Gynecologic and Neonatal Nursing, 35, 662-670.

Friedewald, M. (2007). Facilitating discussion among expectant fathers: Is anyone interested? Journal of Perinatal Education, 16, 16-20.

Friedewald, M., Fletcher, R., & Fairbairn, H. (2005). All male discussion forums for fathers: Evaluation of a model. Journal of Perinatal Education, 14, 8-18.

Gibbins, J., & Thomson, A. M. (2001). Women's expectations and experiences of childbirth. Midwifery, 17, 302-313.

Glazier, R., H., Elgar, F. J., Goel, V., & Holzapfel, S. (2004). Stress, social support, and emotional distress in a community sample of pregnant women. Journal of Psychosomatic Obstetrics & Gynecology, 25, 247-255.

Greenhalgh, R. (2000). Father's coping style, antenatal preparation, and experiences of labor and the postpartum. Birth, 27, 177-184.

Gungor, I., & Beji, N. K. (2007). Effects of fathers' attendance to labor and delivery on the experience of childbirth in Turkey. Western Journal of Nursing Research, 29, 213-231.

Halldorsdottir, S., & Karlsdottir, S. I. (1996). Journeying through labour and delivery: Perceptions of women who have given birth. Midwifery, 12, 48-61.

Hodnett, E. D., Gates, S., Hofmeyr, G. J., & Sakala, C. (2005). Continuous support for women during birth. Birth, 32, 72 (Abstract only).

Howarth, A., Swain, N., & Treharne, G. (2010). A review of psychosocial predictors of outcome in labour and childbirth. New Zealand College of Midwives Journal, 42, 17-20.

Howarth, A., Swain, N., & Treharne, G. (2011). Taking personal responsibility for well-being increases birth satisfaction for first time mothers. Journal of Health Psychology, first published on May 18, 2011 as doi:10.1177/1359105311403521

Howarth, A., Swain, N., & Treharne, G. (in press). First-time mothers' perspectives on relationships with and between midwives and doctors: Insights from a qualitative study of giving birth in New Zealand. Midwifery.

Klaus, M. (1998). Mother and infant: Early emotional ties. Pediatrics, 102, 1244-1246.

Klaus, M. H., & Kennell, J. H. (1997). The doula: an essential ingredient of childbirth rediscovered. Acta Paediatrica, 86, 1034-1036.

Koniak-Griffin, D. (1993). Maternal role attainment. Journal of Nursing Scholarship, 25, 257-262.

Lundgren, I., & Dahlberg, K. (2002). Midwives' experience of the encounter with women and their pain during childbirth. Midwifery, 18, 155-164.

Mercer, R. T. (2004). Becoming a mother versus maternal role attainment. Journal of Nursing Scholarship, 36, 226-232.

Miller, T. (2002). Adapting to motherhood: care in the postnatal period. Community Practitioner, 75, 16-18.

Ministry of Health. (2007). Maternity services consumer satisfaction survey report. Health Services Consumer Research. Retrieved June 17 2008, from http://www.nzdoctor.co.nz/media/ 6422/maternity-services-consumersurvey-report-2007.pdf

Nelson, A. M. (2004). Transition to motherhood. Journal of Obstetric, Gynecologic and Neonatal Nursing, 32, 465-477.

Reid, K., Flowers, P., & Larkin, M. (2005). Exploring lived experience. The Psychologist, 18, 20-23.

Rogan, F., Shmied, V., Barclay, L., Everitt, L., & Wyllie, A. (1997). 'Becoming a mother'--developing a new theory of early motherhood. Journal of Advanced Nursing, 25, 877-885.

Rubin, R. (1984). Maternal identity and the maternal experience. New York: Springer Publishing Company.

Smith, J. A. (1995). The search for meanings, semi-structured interviewing and qualitative analysis. In J. A. Smith, R. Horre, & Van Langerhoue (Eds.). Rethinking Methods in Psychology (pp. 9-26). London: SAGE Publications Ltd.

Smith, J.A. (1996). Beyond the divide between cognition and discourse: Using interpretative phenomenological analysis in health psychology. Psychology and Health, 11, 261-271.

Smith, J. A., Flowers, P., & Larkin, M. (2009). Interpretative phenomenological analysis: Theory, method and research. London: SAGE Publications Ltd.

Smith, J. A., Jarman, M., & Osborn, M. (1999). Doing interpretative phenomenological analysis. In M. Murray, & K. Chamberlain (Eds.) Qualitative Health Psychology, Theories and Methods (pp. 218-240). London: SAGE Publications.

Sosa, R., Kennell, J., Klaus, M., Robertson, S., & Urrutia, J. (1980). The effect of a supportive companion on perinatal problems, length of labor, and mother-infant relations. The New England Journal of Medicine, 303, 597-600.

Statistics New Zealand. (2000). Safety and security: Child abuse and neglect. New Zealand Government. Retrieved August 22 2008, from http://www.stats.govt. nz/analyticalreports/ monitoring-progress/social-cohesion/safety-and- security.htm

Statistics New Zealand. (2008). Average age of first-time mums is 28 years. New Zealand Government. Retrieved November 10th 2009 ,from http://search.stats. govt.nz/ nav/ct2/population_births/ct1/population/ 0

Trochim, W. M. K. (2006). Research methods knowledge base. Web Center for Social Research Methods. Retrieved May 22 2008 from http://www.socialresearchmethods.net/ kb/contents.php

Turan, J. M., Nalbant, H., Bulut, A., & Sahip, Y. (2001). Including expectant fathers in antenatal education programmes in Istanbul, Turkey. Reproductive Health Matters, 9, 114-125.

van Teijlingen, E. R., Hundley, V., Rennie, A., Graham, W., & Fitzmaurice, A. (2003). Maternity satisfaction studies and their limitations: "What is, must still be best". Birth, 30, 75-82.

Vincent, A. (2008). The pink kit. Presentation to the Nelson Marlborough District Health Board 8/02/08, Nelson, New Zealand.

Waldenstrom, U., Hildingsson, I., Rubertsson, C., & Radestad, I. (2004). A negative birth experience: prevalence and risk factors in a national sample. Birth, 31, 17-27.

* Anne Howarth, MSc, Department of Psychological Medicine

Dunedin School of Medicine

Department of Psychology

University of Otago

* Nicola Swain, PhD

Corresponding author

Department of Psychological Medicine

Dunedin School of Medicine

PO Box 913

Dunedin 9054

Email: [e-mail]

* Gareth J. Treharne, PhD

Department of Psychology

University of Otago