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Black women's perceptions of supportive care during childbirth.

Background

Historically, care-giving during childbirth was the responsibility of family members and friends. The philosophy of professional caregivers in many countries has evolved over time with a shift from indigenous folk forms of care to more sophisticated technologically driven forms of care. In an attempt to reduce infant and maternal mortality rates and with advances in medical knowledge, reliance on technology is increasingly more common (Hodnett, Gates, Hofmeyr, Sakala, & Weston, 20ii), and the birth place has shifted from home to hospital for reasons of convenience of caregivers (Enkin, Keirse, Renfrew, & Neilson, i995). As care moved from the unstructured environment of the home to the hospital, caregivers have lost a measure of integration with the community and have become undeniably medicalized (Cindoglu & Sayan-Cengiz, 20i0). These developments and the associated institutional routines may dehumanize the childbirth process as the relational aspect becomes less significant (Hodnett et al., 20ii).

As Tritten (i995) notes, in contemporary Western society childbirth is seen in terms of the activity of the uterus and the acts of the caregivers rather than the activity of a woman giving birth. For example, the discourse surrounding the process is described in terms such as delivery, which assumes health care professionals do the work, that is, they 'deliver' while mothers are relatively passive birthing machines. Bastian O992) notes that "the practice of defining pregnant women by their 'conditions' may be convenient and informative between professionals but it is quite literally depersonalizing" (p. 92). As a midwife and a perinatal nurse, I am often amazed at the list of things women are told they have failed at during the birth process. Birthing women are described as 'failure to dilate,' 'failure to progress,' and 'failure to thrive' (i.e. their babies). Other dehumanizing language of the perinatal system include 'incompetent cervix,' 'inadequate pelvis,' and sometimes the entire human being and her baby can be reduced to 'a prolapsed cord.' This language that implies failure, inadequacy and incompetence may have adverse effects on the confidence and self-esteem of the non-medical consumer (Bastian, i992). Barker (i998) notes that the power embedded in biomedical discourse is a mechanism facilitating the view of pregnancy as a disease requiring "diagnosis" and only physicians possess the sufficient means by which to "diagnose." The focus is shifted away from what women could do to ensure safety for themselves and their babies as a natural biological process, to a need for a physician. The reliance on obstetrical technology to manage pregnancy contributes to lack of a holistic care in the childbirth experience.

The emerging caregivers in today's perinatal care system include childbirth educators, midwives, family physicians, obstetricians, perinatal nurses, lactation consultants, and doulas. While some of these perinatal care providers view birth as a pathological event in need of medical supervision, (a belief influenced by early obstetricians who argued that normal childbirths are exceptions and that to consider them normal physiologic processes would be misleading), others view childbirth as a natural process (Enkin et al., 1995). Most women share in this belief of childbirth as a natural process which requires few medical interventions (Fraser & Hughes, 2009). Based on this belief and in recognition that medical interventions may carry their own risks, some women are now opting for more control and fewer interventions. More healthy pregnant women are choosing to have a low intervention approach to perinatal care where a trained perinatal caregiver who shares their beliefs about childbirth, who knows and understands them in the context of her family, can manage their childbirth (Reid & Garcia, 1989).

The purpose of this paper is to present one of the findings (supportive behaviour) of a qualitative study that examined the childbirth experiences of African Nova Scotia women. The study Research Methodology is described below.

Method

The purpose of this qualitative study was to explore the childbirth experiences of African (Black) Nova Scotia women within the health care system with a goal of generating information that will enable health care professionals to provide culturally competent care for this population. The following research questions facilitated the research:

1. What are the experiences of African Nova Scotia women regarding childbirth with the health care system?

2. What are the suggestions and recommendations of African Nova Scotia women regarding the strategies that would help health care professionals to best meet their perinatal care needs?

Setting

This research was conducted in the North End Community Health Centre located in the capital city of one of Canada's Atlantic provinces. The main forum of research activities was the Black Women's Health Program which is located within the Centre. A significant number of the users of this health facility are Canadians of African descent. In keeping with the principles of feminist participatory action research (PAR), the study was initiated in collaboration with Black women from this group and they were actively engaged with the project throughout the research and dissemination process (Etowa et al., 2007).

Participants

Ten indigenous African Nova Scotia women, ranging in age from i8 to 40 years who had experienced the childbearing process within a two year-period of the study were interviewed for the research. Five of the women were primiparae (first-time mothers) and the other five were multiparae (women who have had two or more deliveries). Out of the five multiparae, one was a second-time mother, three were third-time mothers and one was a fourth-time mother. Marital status was not a determining factor in participation. Three of the women were married, one had a common-law partner and the other six were single mothers. The level of education varied within the group, ranging from Grade 10 to a Master's degree. All participants worked outside the home. Ethical approval was obtained from Dalhousie University Research Ethics Board (REB).

Data Collection and Analysis

Participants took part in individual interviews and focus groups. Interviews took place within two years of delivery date. Following the completion of each individual interview, participants were invited to focus group meetings. Focus groups were conducted six weeks following the completion of individual interviews. These meetings served two purposes; data collection and validation of the researcher's preliminary data interpretation. Both interview and focus group audiotape recordings were transcribed verbatim and manually coded. Thematic analysis method was used to interpret and identify the key patterns or themes in the data. The findings of this study comprised four key themes; the meaning of childbirth experience; racism within the health care system; cultural competence and access to health care; and supportive behaviours during childbirth. The theme of supportive behaviours during childbirth will be the focus of this manuscript.

Findings

Supportive behaviours during childbirth, a key finding of the study, will be the focus of this paper. The perceptions of childbirth are highly personal and individual, thus there is variance in what constitutes a positive or negative experience. Supportive practices from both family and health care professionals facilitate a woman's transition through the child-bearing process and often enhance her positive feelings about the experience. The study participants described supportive behaviours in various ways which have been categorized as 'family' and 'health care providers' as support systems.

Family as a Support System: Social and emotional support provided by family members ranged from the informal sharing of knowledge to supportive behaviours. These behaviours include physical and emotional presence, comforting, holding and touching, babysitting, 'being there', reassurance, coaching and showing concern. In terms of physical presence, one woman said,
   My family is my number one support ... I don't know what I would do
   without my mother. If I'm not around, my mother would be there. I
   leave my kids at her place because I know someone will be there,
   even if my mother is not there.


Similarly, another participant recalled, "When my mom found out, she was pretty supportive and she helped me. My family cared about me and that just made me feel like the baby was really, really important." Another woman described her family support as: "My aunt, she was great. She did everything for me. She did a lot of things for me, like going to get me face cloths, ice, popsicle. Everything like comforting me, talking to me. She was helpful." The importance of family support is illustrated by this quote from one of the participants. She said,
   I don't know if I would be able to do it. She was encouraging me to
   do it, to keep going. In terms of seeking information, I usually
   call my grandmother. She gives me answers that I can understand.
   She talks to me in "normal words."


One woman felt that, in addition to family, her main resources were people who have gone through the experience. She noted: "One of the biggest resources that you could have, is when you've met someone that's been through the experience." Another woman felt that community resources centres such as Stepping Stone were her main resource. She explained, "Stepping Stone is like my family." These various forms of supportive behaviours lead to the accomplishment of a positive childbirth experience.

Current evidence suggests that a labouring woman's need to feel secure is usually accomplished through the presence of close-knit family members and friends, which makes her feel not only protected, but also not being observed or judged by health care providers (Ngai, Chan, & Holroyd, 2011). Oxley and Weekes (i997) found that African American pregnant adolescents appraised their experience as either easy or hard based on the availability of family support and other actual or perceived resources. Women in their study described the childbirth experience as easy if they had a supportive mother and those who described it as hard had limited supports and interpersonal conflicts with family members. Furthermore, Jambunathan and Stewart's (i997) study of family support among fifty-two childbearing women found that seventy-five percent of the women in their study reported that family support was helpful and they described support to include taking care of baby, giving helpful advice, and comforting when the baby is fussing and crying.

Health Care Providers as a Support System: All the study participants acknowledged the supportive behaviours of the health care providers they encountered during childbirth. The supportive behaviours described in the study were in the forms of physical presence, caring attitudes, provision of information, nature of assessment, and coaching. Physical presence was described as:
   They were always there, they didn't leave me alone for too long. It
   made me feel comfortable and secure ... The nurses are the ones
   that give you the personal touch, personal care. They actually give
   you that one-on-one care. The ladies who looked after me did their
   job ... they were gentle, and they were nice. They made me feel
   comfortable ... That stood out in my mind.


Another woman said,
   The nurse for my third child really did stand out...she would come
   and sit down and just talk with me, even while the doctor wasn't
   there. And she understood. You know how people get down to your
   level. She was very personable.


One participant felt that having a Black nurse look after her baby while in the special nursery made a difference because:
   She [the Black nurse] knew my baby and her needs. She's not a White
   baby and she knew a lot about her, and a lot about me too...about
   her skin, eczema and stuff like that. She taught me a lot. She
   really made sure that I was called to come down and feed her.
   Although all the nurses down there told me how much she gained and
   stuff like that. Seeing this nurse down there ..., someone I can
   relate to made a big difference.


On the other hand, one woman felt that it does not take being Black to meet the needs of Black women. She explained, "it doesn't take being Black. She wasn't Black ... you just have to be good at what you do and be very personable." She elaborated that what made the difference was the nurse's interest in knowing her past experiences and how she deals with stressful situations. The nurse also asked her how she can help her deal with the labour pain. Coaching was a practice several women identified as supportive behaviour. One woman explained:
   They had to break my water and I wouldn't let them do it so she
   suggested I take the gas. She asked me how I was doing and she
   explained what I should do, and she coached me how to do it. "She
   was right there with me.... she was a caring person."


One of the participants felt that her nurse supported her by not discouraging her from using her own strategies. "She was helpful to me because whatever I wanted, she supported. She wouldn't discourage me from something. She understood me, and the pain I was going through. She was going through it with me. Yes, it was like she had the pain with me." One woman felt that her physician displayed caring attitude by encouraging early contact with her baby:
   Once he was out, my doctor put him right on my chest ... an
   experience I never had with my first. He was on my belly for a
   little bit, and then they took him and did the necessary cleaning
   and stuff. And then, of course, he was back. The fact that he was
   given to me right after birth was really great ... I actually felt
   like a mother from the beginning.


'Friendly' and 'welcoming' attitude towards family members was comforting for some women while some felt protecting the privacy of their situation was important. For example young mother indicated that her care providers,
   ... were very helpful. They gave me milk tickets, prenatal classes
   and talked to me about a lot of stuff. And when I didn't tell my
   mom, they knew, and they were okay about it. They told me I could
   tell my mom when I was ready. And they still helped me.


Consistent with the supportive behaviours described by the women in this study were those of Adam and Bianchi (2008) who described the supportive behaviour employed by nurses in childbirth as "physical, emotional, instructional/ informational, and advocacy" (p.i06). Elements of social support from existing literature include acceptance, reassurance, listening, assisting with problem solving, showing attention and affection, and meeting physical needs for transportation and clothing (Hodnett et al., 2011; Ngai et al., 2011).

Discussion and Implications

Although western society has made substantive improvements in the care provided in childbirth, these improvements have by no means reached all segments of society. Within the context of globalization, a large number of immigrants now make up a large part of the childbearing population in Western society. They are at a considerable disadvantage in terms of access to, and utilization of perinatal care particularly regarding their own cultural desires (Etowa, Weerasinghe, & Eghan, 20i0). To foster supportive care during childbirth, perinatal care organizations should build collaborative partnerships with members of various communities, especially those in vulnerable situations, and invite them to actively participate in planning, monitoring and evaluating programs or services. Collaboration between health care providers and their communities enables both parties to create a common vision as information is shared and feedback obtained from both sides. This kind of relationship fosters an atmosphere of mutual respect where members of marginalized groups can feel empowered to reclaim their voices in the decisions influencing their health care.

A number of studies suggest that not only is confidence greater after childbirth education, but confidence is powerfully related to decreased pain perception and decreased analgesia use during labour (Crowe & VonBaeyer, 1989; Lowe, 1991; Waldenstrom & Nilsson, i993). Green, Coupland, and Kitzinger (i990) found that women who are better prepared and supported prenatally had more confidence in their ability to manage labour and delivery, and they also reported a less painful experience. A recent systematic review of the evidence on supportive care in labour found that women provided continuous support in labour were more likely to have spontaneous vaginal birth, to have shorter labour and less likely to require pharmacological pain relief measures (Hodnett et al., 2011). Hodnett (i996) also found that women who had extra support had shorter labours and were less likely to have any analgesia/anaesthesia use throughout the process, an operative vaginal delivery, or a caesarean section. Infants delivered by these women were less likely to have a five-minute Apgar score of less than seven and the women were likely to rate their childbirth experiences negatively (Hodnett, 1996). In this technological age, childbirth educators and other perinatal care providers need to understand the importance of women's views when considering different methods of managing childbirth. While some women would benefit from a caregiver who encourages the use of obstetric analgesia, others might prefer the use of non-pharmacological supportive strategies (Adam & Bianchi, 2008; Amoros et al., 2010; Fraser & Hughes, 2009). The challenge for the caregiver is to be sensitive enough to assess those needs properly.

Given the vital role of the supportive behaviours of family and friends, it is necessary for childbirth educators and other care providers to understand the family dynamics and support systems for women during childbirth. The literature suggests that the promotion of family support and the use of personal resources within the context of culture will create an empowering and culturally safe environment for women to birth (Callister, Corbett, Reed, Tomao, & Thornton, 2010; Callister & Khalaf, 2009). Creating a culturally safe birthing environment calls for the integration of cultural competence and safety models into educational curricula of childbirth educators and other care providers (Greene, 2007). Perinatal care providers such as Childbirth educators should be nonjudgmental when working with the childbearing woman and her family because this will help her fulfil her need for control and nurturing. Being caring to a woman enables her to be herself and to go through a successful birth experience as an active participant. Finally, as we care for a woman and her family, we can be sure that her perception of the experience will carry the potential for positive or negative impact on her development as a woman and mother, and on the future of her baby. As Rothman (1996) stated, "birth is not only about making babies. Birth is also is about making mothers--strong, competent, capable mothers who trust themselves and know their inner strength" (p. 254).

Acknowledgement: This study was funded by the IWK Health Centre Ruby Blois Award

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Josephine B. Etowa PhD RN

Dr Josephine Etowa is an Associate Professor in the Faculty of Health Sciences at the University of Ottawa. As a perinatal nurse, a midwife, a lactation consultant, a researcher and an educator, Dr Etowa has worked in various capacities including clinical practice, research, education and health consultancy in Canada and abroad. Her research is in the area of health equity and ethno-cultural diversity with studies that focus on maternal-child health and cultural competence in health care.
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Author:Etowa, Josephine B.
Publication:International Journal of Childbirth Education
Article Type:Report
Geographic Code:1CNOV
Date:Jan 1, 2012
Words:3739
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