Giving Birth

J Perinat Neonat Nurs Vol. 24, No. 2, pp. 1–9 c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright

Giving Birth The Voices of Australian Women Lynn Clark Callister, PhD, RN, FAAN; Shelley Thacker Holt, BSN, RN; Melody West Kuhre, BSN, RN Background and significance: Women’s perceptions of childbirth are defined within sociocultural context. Listening to the voices of women is essential to increase nurses’ sensitivity to the needs of childbearing women and help nurses provide culturally competent healthcare. Purpose: The purpose of this qualitative descriptive study was to identify Australian women’s perceptions of giving birth. Method: Seventeen Australian women who had given birth in the past 12 months participated in audiotaped interviews. Trustworthiness of the findings was ensured. Themes were generated on the basis of rich narrative data. Results: Themes included focusing on the moment of birth, being empowered by giving birth, defining the spiritual dimension of giving birth, having a diminished or traumatic birth, feeling concern for the child, coming to know the child, and receiving care: nurses making a difference. Implications for clinical practice: Results confirm the findings of other studies suggesting that provision of educational resources and individualized nursing care creates a climate of confidence in childbearing women. Key words: Australian women, childbirth, qualitative inquiry

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omen’s perceptions of childbirth are culturally bound. Studies have been conducted of diverse childbearing women in the developed and developing world.1–5 Healthcare should be based on qualitative data documenting the perspectives of women. Through such research, nurses’ sensitivity to the needs of culturally diverse childbearing women can be increased.6 Researchers conducting a prospective study of maternal role development in Australian women concluded that healthcare professionals need to gain a deeper understanding of the experiences of childbearing women.7 Because of recent trends in delaying childbearing and an increased number of maternal requests

Author Affiliation: College of Nursing, Brigham Young University, Provo, Utah. Corresponding Author: Lynn Clark Callister, PhD, RN, FAAN, College of Nursing, Brigham Young University, 136 SWKT, Provo, UT 84602 (lynn [email protected]). Submitted for publication: May 28, 2009 Accepted for publication: December 10, 2009

for elective cesarean births in Australia, the need was seen to listen to the voices of Australian childbearing women. The purpose of this qualitative descriptive study was to identify perceptions of Australian women about giving birth.

BACKGROUND AND LITERATURE REVIEW Perinatal healthcare in Australia In Australia, the population growth rate is 1.221% and a natural increase in 2008 was 3.1% greater than that in 2007.8 Australia has a fertility rate of 1.93 children born per woman, and the birth rate is 12.55 births per 1000 population. The infant mortality rate is 4.82 deaths per 1000 live births. Ninety-two percent of the population is white.9 Sixty-six percent of Australians live in major cities. Victoria is the smallest Australian state with the second largest population (more than 5 million people). In 2005, 63 000 Australian women gave birth. There are 60 public hospitals that provide maternity 1

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Journal of Perinatal & Neonatal Nursing/April–June 2010

services.8 Public hospitals have a variety of services including neonatal intensive care units and medical specialists, depending on the annual birth census.10 Australian sociocultural trends include declining birth rates and smaller nuclear families, with more mothers employed outside their homes and more women seeking graduate education. Eighty-one percent of children live in 2 parent families. Some Australian women are often delaying childbearing until after they are 35 years of age.11 Mean maternal age in 2006 was 29.8 years compared with 28.7 in 1997, and 21.4% were 35 years or older. Fourteen percent of first births were to women 35 years or older compared with 8.3% in 1997.12 They may describe new motherhood as an isolating experience.12 Other couples are choosing to remain voluntarily childless. Since the 1970s the fertility rate has been below replacement level, meaning that many women are averaging fewer than 2 children. Because of the declining birth rate, the Australian government has implemented a “baby bonus”incentive for having a child. This may have resulted in a 2008 natural increase being 3.1% than that of 2007.8 Basic healthcare is covered regardless of socioeconomic status through national health insurance. Primary services are provided to low-risk women, who receive prenatal care with an average of 6 visits during their pregnancy, once by a family physician and then cared for by midwives who attend their births. The UK midwifery model of education is utilized, which means that becoming a midwife is a specialized basic degree in nursing, most often with a baccalaureate education. First-time couples take childbirth education classes offered at public hospitals by midwives. Secondary services are available for women at risk for complications, and these women are comanaged by midwives and obstetricians. Tertiary services are available for childbearing women and their unborn children with complex or rare medical conditions requiring multidisciplinary specialist care (a team of perinatal and neonatal experts). Australian women enjoy multiple healthcare options, including public/private healthcare, varied providers (midwives, family physicians, obstetricians), and giving birth in public or private healthcare facilities. Home births are discouraged and no funding is available to cover the cost of such births. In 2005, 97.5% of Australian women gave birth in hospitals, with 0.2% home births and 1.9% birthing center births. The median length of stay is 3.0 days for women having vaginal births, and 5.0 days for those having cesarean births.12 Thirty percent of women have private insurance, with 30% of the premiums subsidized for private obstetric care.

Australian women may also choose to give birth in birthing centers. Although there is no consensus on the definition of a birthing center in Australia, such facilities may be freestanding (a separate site adjacent to medical centers) or alongside a hospital labor unit. Regardless of location, birthing centers espouse a philosophy that includes a homelike environment, familycentered midwifery care, and a commitment to facilitating a normal physiological birth. A recent study concluded that the total perinatal death rate in Australian birthing centers was significantly lower than that in hospitals.15 Women who give birth vaginally in freestanding birth centers and public hospitals go home anywhere from within a few hours to having a 48-hour stay. Obstetricians attend births in public hospitals if women are at high risk or if they have cesarean births. Births in these facilities are publicly funded by the Australian government. Women may also purchase private health insurance instead of using the public system if they prefer to give birth in a private hospital with an obstetrician attending their births. Women who prefer continuity of care across the childbearing year may also purchase insurance. Families above a certain income level may actually be required to purchase private health insurance. Australia has no national system of obstetric anesthesia audit, so the rate of obstetric epidural analgesia/ anesthesia administration is not known. It is more common to use nitrous oxide and pethidine (an opiate similar to morphine) rather than having an epidural. Epidural analgesia/anesthesia is not available in most birthing centers but is available in both public and private hospitals 24 hours a day from obstetric anesthesia staff. Most fathers attend the births and actively support their partners during labor and birth. The rate of cesarean births in 2007 was more than 30% (compared with 20.3% in 1997), with a recent survey of Australian obstetricians (98.6% response rate) reporting that 3% of all births are cesarean for maternal request.16 The reason for this trend is yet to be determined. The majority of new mothers breast-feed and take a full year’s leave from their employment. In the district of Victoria, community midwives make home visits to the maternal/newborn dyad without cost. Pregnant women receive maternal/child health records that track maternal health, immunization status, well child checkups, and other pediatric visits. The Web site affiliated with this record is http://www.bestart.vic.gov.au. [AQ1] Australian studies of childbearing women The Victorian Surveys of Recent Mothers described Australian maternal newborn healthcare.17 In

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1998–2000, the 3 largest obstetric hospitals in the district of Victoria developed guidelines for evidencebased healthcare for mothers and infants.18 A Web site called Having a baby in Victoria was developed, which provides information about options for care and how to get the most from healthcare. The Web site includes a section titled “What does research/evidence tell us?” describing current evidence on pregnancy and childbirth. On the Web site, research studies are summarized with suggestions for evaluating research quality, strength, and relevance.19 Australian studies of childbearing women Australian studies of childbearing women and midwives were reviewed. It was found that Australian midwives are seeking to promote normal birth and expand the utilization of the midwifery model of care with shared decision making.20–24 A grounded theory has been generated documenting how 19 first-time Australian mothers prepared for their first births, with categories including finding a childbirth setting and setting up birth expectations.25 Another grounded theory was generated in a study of 13 expectant nulliparas, who identified diverse experiences with pregnancy, describing challenges coping with physical and emotional symptoms. The women identified the need for more education. Some described a sense of losing control, which shifted over the course of pregnancy from “wanting to be in control of events to accepting responsibility, being assertive, and making choices based on knowledge.”26(p245) Five Australian expectant mothers described accepting pregnancy and their evolving sense of maternal identity.27 These studies focused only on pregnant women’s perspectives. In a descriptive qualitative study of Australian firsttime mothers,28 it was noted that many women felt unprepared and felt that they had little influence over their birth experience. One hundred forty-one Australian women’s accounts of labor and birth in a public hospital were analyzed. Themes included anticipating labor and birth, birthing depicted, mediating factors and their consequences, and evaluating and looking ahead.29 In another study, Australian women viewed having a cesarean birth as a convenient way of giving birth.30 The social context of Australian women’s fears of childbirth has been explored, concluding that positive relationships with midwives and having social support networks mediated their fears.31 A qualitative study of Australian childbearing women identified 5 major themes, 3 of which were positive: “owning and believing in birth as a natural event,”

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“satisfaction with the birth process and outcome,” and “involvement and participation in the birthing experience.” Two additional themes were less positive, with birth perceived as a negative and largely medical event. Expectations of childbirth have a strong influence on Australian women’s perceptions of childbirth.32,33 The need for additional inquiry was noted, given the increasing maternal age at first birth and the increased demand for elective cesarean births. This qualitative descriptive study documents the lived experience of giving birth in the voices of Australian childbearing women.

METHODS This qualitative descriptive study was conducted in Geelong, Australia, located in the state (district) of Victoria. The study was conducted in Victoria because it is the site of the 3 Centres Collaboration, which focuses on applying the best available evidence and expertise to the care of childbearing women and their families. Following institutional review board approval, a convenience sample of Australian women who had given birth in the past year was obtained. Following informed consent, audiotaped interviews were held with 17 women. Study participants were asked open-ended questions focusing on their perceptions of their birth experience (Table 1). Data analysis proceeded concurrently with data collection. Data collection continued until saturation occurred. The audiotaped interviews were transcribed verbatim. Trustworthiness of the qualitative data (similar to reliability/validity in quantitative inquiry) was ensured through establishing credibility, transferability, dependability, and confirmability.34 The following techniques were utilized. Members of the research team independently performed preliminary analysis, engaging in reflection and extracting significant data bits. Researchers reflected on the sociocultural context of the study participants and attempted to represent the perspectives of the study participants in data analysis. The preliminary results were compared and primary themes identified.35

Table 1. Interview questions What was the best thing about being pregnant? What did you think childbirth would be like prior to giving birth? What were your feelings when you first saw your baby? What would you do differently if you had another baby?

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Themes were generated on the basis of the rich narrative data.36,37 Member checks were done with 5 study participants to confirm whether the findings reflected the experiences of the women participating in the study. Insights were generated and described on the basis of the narrative data.

FINDINGS Demographic data are given in Table 2. Women used the following word descriptors to define what giving birth meant: empowering, exciting, anxiety producing, painful, rewarding, filled with happiness, the source of joy and elation, and challenging but bearable. One woman said, “I felt overwhelming love. I could have never imagined what it would be like. I don’t think I’ve ever felt anything like it. It was just amazing.” Themes included being focusing on the moment of birth, empowered by giving birth, defining the spiritual dimension of giving birth, birthing as trauma or having a diminished birth, feeling concerned about their child more than themselves, coming to know the child, and receiving care: nurses making a difference. Focusing on the moment of birth Study participants spoke emotionally about how they felt at the moment their child was born, “The obstetrician made it about one minute before [the baby was born] and I was kneeling on the ground, and they just got underneath and delivered him. He didn’t breathe for a little while, which concerned me, but then he was okay.” Another mother said, “He [the baby] came out screaming. I was bawling my eyes out. He was crying, I was crying, and my husband was crying. It was fantastic.” Table 2. Demographic data

[AQ6]

Age range, 25–35, mean of 33 years 15 whites, 1 Asian, 1 black All married or in a committed relationship Maternal education: 16% less than high school, 25% high school graduates, 25% college graduates, and 34% having some graduate education Parity: 8 primiparas, 9 multiparas Abortions: One had 2 medical abortions, 2 women had spontaneous abortions Number of prenatal visits: range, 6–13 Births: 14 vaginal (9 unmedicated), 3 cesarean births Birth attendants: 5 physicians, 5 midwives, 7 both Birth setting: 2 private hospitals, 4 public hospitals, 11 birthing centers

A woman who gave birth in a public hospital after being induced at 41 weeks’ gestation said, “One of the midwives came in and checked me. She said, ‘You’re fully dilated. You can push.’ About six pushes later, he was born.”Another study participant described her experience in this way, “[When I first saw my baby] I was blown away—just amazed that she grew inside of me. It’s pretty incredible. I just keep thinking she’s just such a miracle.” Another mother described her feelings associated with having a new baby, “There is instant love and a very natural feeling devoted to him.”A first-time mother articulated, “There’s nothing else like it. There’s nothing else like it. There’s nothing that you would do that is anything like it. It’s amazing—creating your own baby and then giving birth to it.” A study participant described giving birth to her third child, a son, My husband had tears in his eyes and he’s a pretty tough sort of bloke. And that was lovely. It’s just something I hadn’t felt until I had children. It’s something primal, a gut feeling of protection, of just pure love. It’s amazing. It was, for me, instant. It was just complete awe.

Being empowered by giving birth Participants described themselves as “Aussies”wanting to exercise considerable control over decisions relating to their pregnancies and birth with input from their caregivers as consultants. They were strong, articulate women who viewed childbirth as a life-changing wellness experience. Many study participants preferred to avoid having epidural analgesia/anesthesia and viewed the challenges of childbirth as symbolic of life challenges that occur across the lifespan, “[Giving birth] makes you more resilient. You know you are able to handle things that you didn’t think you could. I think it gives you strength because you know if you can get through that, you can cope with a lot of other things.” Another woman contrasted her first birth with epidural analgesia, I was awake, but I was numb” with her second birth, which was un-medicated. I experienced full-on labor, and that was just the most amazing experience. Oh my gosh, you think you are going to die. So I’m glad that I went through it and I felt it and I’m amazed that I did it, but I don’t know if I want to do it again! My body is capable of a lot more pain than I give it credit for! Your body is amazing and is designed to give birth. Mothers all over the world have done it, and I did it!

One study participant giving birth to her third child said, It’s hard to describe childbirth, and after you have given birth you just feel this amazing accomplishment—like you’ve done this amazing thing. You feel like you can conquer the world

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and you can’t believe that millions of women do it numerous times over. Women have been birthing since the beginning of time.

Defining the spiritual dimension of giving birth Although most study participants were not religiously active, some identified the spirituality of giving birth. A woman who gave birth to her second son said, I am a Christian. I prayed that Jesus would be in that [birthing] room with me and helping me. I just prayed that He would catch the baby when he was born. . . . I believed that He was there. I knew it was God’s plan. I just felt like it was spiritual.

Most of the study participants said that birth was not a spiritual experience, but described emotional feelings or having a “connected”experience with a Higher Power, a profound or life-altering experience, or emphasized the power of creation. For example, a firsttime mother reflected, I didn’t think [about childbirth being a spiritual experience] at the time, but looking back I do. I think it’s just the way you connect with your baby in a way that you’ve probably never connected with anything. It gives you a whole different perspective on your spiritual side.

Another mother could not articulate what a spiritual experience was, but expressed her feelings about associated emotions, “By spiritual, I don’t know what you classify as spiritual, but having created this baby from nothing and giving birth to it—it’s so emotional and loving. It’s like nothing else.” Another study participant reflected on the spiritual dimension of giving birth, Mum said to us afterward, “that’s got to make you think twice about religion, such an overwhelming experience.” It is truly amazing. It’s profound. You’ve got two of you, and then all of a sudden the two of you have become three within a family unit. I could understand how someone could see it as a spiritual thing.

For some women, the type of birth affected whether or not they viewed birth as spiritual. For example, a woman who had a cesarean birth after 2 vaginal births insightfully compared her varied birth experiences, The other two [births] were definitely spiritual experiences, but Emily was purely medical, there was no spirituality. When you give birth and you’re doing it yourself you’re taken to another place, but with Emily I wasn’t giving birth myself. The doctors were cutting me open and taking her out. There was no spirituality that I felt during birth. It was very mechanical, it was very precise, it was goal oriented.

Birthing as trauma or having a diminished birth Three study participants described their births as traumatic, including the woman who was just cited. One

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woman who had a precipitous birth with a third-degree tear said, “I was scared. It was so quick. I was scared and didn’t know if I would be able to cope with the pain.” A woman who had been told she would have a cesarean birth for failure to progress and then gave birth vaginally said, Once he was out after the minute of pushing, I was just in shock. My body was shaking because one minute we’re talking about a Cesarean and the next minute the baby’s on your chest. It was overwhelming—the first hour after having him. It all happened very, very quickly.

Another study participant who experienced a traumatic birth said, [The birth] was a blur. The whole birth experience was overwhelming. I was just in shock for at least 24 hours afterwards. For the first month after, I couldn’t really talk about it. It was so intense, and about three days after, I had talked to Jeremy about it and had a little cry. It was just so intense. I needed to debrief. At the time I thought that I would never want to do that again.

Feeling concern for the child An overwhelming majority of women felt concern for their unborn child. Some of their comments included, “I would just pray all the time that the baby was going to be healthy and normal” and “The labor itself wasn’t something that really concerned me. It was more about actual baby safety that was more of a concern.”Another said, “My main goal was to have a healthy baby.” One woman identified the importance of “having a healthy baby at the end. I met my goal.” Another study participant described the change she experienced in her life, “Before you have a baby, it’s all about you. Then you have a baby and you don’t get five minutes to yourself anymore. It just shifts the focus to what’s important. Now he’s the most important thing in my life.” Experiencing the pain of childbirth A first-time mother who experienced a water birth said, “It was incredibly intense and painful.” Another said, “It’s not a pain you can describe.”Another mother said, “I wasn’t quite prepare for the intensity of the pain. . . . I was overwhelmed by how painful it is.” A mother who was determined to have an unmedicated birth said, “I just knew that pain doesn’t last forever.” In a study of first-time Australian mothers, researchers concluded that “a positive birth experience does not exclude pain.”37(p466) Women who had epidural anesthesia described a different kind of experience, “When I was in labor, I was laughing and happy. Whatever is going to happen will

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happen. I didn’t find anything hard because I had the epidural.” Another woman said, It was just more intense than I thought it would be. Again— what do you expect? You just don’t know what to expect in the first place. It was painful. I guess it’s bearable. You do get through it. It was harder, I think, because I was induced. . . . The labor pain was just intense and nothing helped. Showering didn’t help. Being in the right position didn’t help. They told me I was dilated to six centimeters and I thought, “Oh, my God.” That’s when I said, I can’t do this for another four centimeters. I need an epidural.” Once the epidural was in, I was a different person. I was much more relaxed. Then I had more excitement that he was coming.

Coming to Know the Child A woman who had in vitro fertilization to conceive her first child unexpectedly and joyously became pregnant a little over a year after her first birth. She took 7 pregnancy tests before believing that she actually was going to have a baby. She described the moment of birth, “I couldn’t believe a baby just came out. . . . When she came it was just all worth it. All that pain just disappeared instantly, and I just saw her and it was amazing. . . . Once I held her, she had a little smile. She just looked right at me.” She also said, “It is interesting you can love somebody so much but then still actually have enough for another child.” Another mother said, [I was] amazed at what he looked like. He looks exactly like my husband. I always thought I was having a girl too, and I thought I would have this blonde-haired blue-eyed girl. He has big brown eyes and jet black hair.

However, this feeling of instant love and devotion was not universal. Another study participant described a different experience regarding coming to know the child, It’s not like they put the child on you and you fall in love with the child. That just didn’t happen to me. They put the baby on me and I thought, “He smells funny and why haven’t you washed him and I am tired, I want a shower.”

Receiving care: Nurses making a difference Study participants described how nurses (midwives) provided realistic advice including discussing options, offering encouragement, expressing confidence, acting as advocates, providing space and privacy, demonstrating genuine care and concern, and involving family members in care. One woman said, [My midwife] is just wonderful. She was just a very sensible, down-to-earth sort of person. She gave me very good advice. She knew what I was capable of and when to encourage me.

She would give me regular updates on how I was doing. She was very honest with me.

Another study participant noted, The midwife is really important. The environment she creates helps you create, and her confidence in you is really important. They did wonderful things for me . . . they created the environment that I wanted. While I was doing really well, they just let me do it.

A third woman said, I don’t even remember her name but I know her face. She was awesome. She was great. She did everything. She made sure that I was comfortable. She was very personal. I didn’t feel just like another patient. She individualized. I can’t even remember the doctors. I know they were there but the nurse [midwife] is the one that sticks out in my mind.

DISCUSSION Although each woman’s birth experience was unique, similarities emerged from the data. Themes generated reflect these similarities as well as some differences. The themes documented the perceptions of Australian women. Results confirm the findings of other Australian studies.7,20–33,38 Many of these themes are also reflected in studies of culturally diverse women giving birth in their own sociocultural context and varied healthcare delivery systems.1–6 Study participants focused on the moment of birth as a pivotal life event, a time of transition to motherhood and an appreciation of the opportunity to participate in the creation of life. Study participants described feeling a sense of empowerment giving birth as an act of creation as selffulfillment. This empowerment contributed to women experiencing enhanced self-efficacy. This is confirmed in Parratt and Fahy’s work39,40 about fostering a sense of self in Australian childbearing women. Some of the women articulated a sense of spirituality in the transcendent moments of bearing a child, regardless of whether or not they were religiously devout. This theme has been documented in a summary of studies with other culturally diverse women.41 Three of the study participants reported a sense of diminished or traumatic births. Women’s negative perceptions of birth have also been reported in the literature.33,42,43 Some of the women reported watching reality television as a source of information about birth. The influence of the media cannot be minimized and may contribute to unrealistic expectations and fears.44 Web sites available to Australian women provide them with the tools to critique research evidence related to childbearing, serving to create a “climate of

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confidence” rather than a “climate of doubt.”45 This may be helpful in decreasing women’s fears and anxieties about giving birth and minimize elective cesarean births by maternal request. Most of the women focused on ensuring positive outcomes for their child as their primary concern rather than their own well-being. Study participants stated that their overwhelming concern during pregnancy was the health and well-being of their unborn child. As the study participants made the transition to motherhood, they described the process of coming to know their child as their own. Seeing their newborn for the first time was an incredible experience for these women. All of the study participants articulated the essential role of the nurse in contributing to a positive birth experience. A strong theme was the valuing of nursing care during labor and birth. The importance of continuous support is also well documented in the literature.46 These interviews also demonstrate the significance of individualizing nursing care. Several participants identified the importance of having constant support during their labors, whereas other participants preferred to have more space. Results confirm the findings of other Australian studies7,20–33,38 and studies of culturally diverse childbearing women,1–6 suggesting that provision of educational resources and individualized nursing care creates a climate of confidence in childbearing women. Australian women expect and appreciate shared power with their caregivers and desire an enhancement of self when they give birth.39,40 Implications for nursing practice In the provision of healthcare for childbearing women, the importance of caring, connection, and shared power between nurses and childbearing women to ameliorate potential negative psychosocial outcomes cannot be overemphasized.47,48 Factors related to the quality of the birth experience are amenable to nursing interventions, including decision making and fostering a maternal sense of control.49 To enhance the birthing experiences, the provision of care should be characterized by caring and respect, including the provision of emotional support, comfort care, education, and advocacy.50–52 Such care creates a “climate of confidence” rather than a “climate of

REFERENCES [AQ3]

1. Amoros Z, Callister LC. Giving birth: the voices of Armenian women. Int Nurs Rev. In press.

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doubt”and is linked to positive psychosocial outcomes in birthing women.19,42,53,54 An essential nursing intervention is facilitating women to have the opportunity to share their perspectives of giving birth. This may include birthing or clinic nurses simply asking women who have recently given birth to share their birth experiences. This cognitive processing can provide the opportunity for the woman to integrate a life-changing experience into the framework of her life, share a significant life event, and discuss fears and concerns or feelings of inadequacy or disappointment in order to gain an understanding of her strengths and connect with other women.6 As part [AQ2] of an interdisciplinary healthcare team, a unit-based social worker may also fulfill this role. Documentation of outcomes related to such interventions is very important. Limitations Limitations of the study include interviewing a homogenous well-educated convenience sample of Australian women. Findings may not be generalizable to all Australian women giving birth, because the study included only one immigrant and a small number of women with varied ethnic backgrounds. Also the majority of study participants gave birth in a birthing center. Recommendations for future research “The importance of listening to women and their partners in evaluating and carrying out research on maternity care cannot be underestimated.”55(p73) Conducting further studies with culturally diverse Australian childbearing women, including immigrant women, is recommended. An intervention study testing the effectiveness of listening to women describe their birth experiences would be helpful.57,58 Use of the Care in Obstetrics: A Measure for Testing Satisfaction (COMFORTS) Scale, which measures birthing women’s satisfaction with their care, contributing to assessment of care quality, is also recommended.38 The World Health Organization agenda for women’s health includes a focus on making health systems work for women, not only access and comprehensiveness, but also responsiveness to the needs of women.59 Examining healthcare delivery through the lens of women’s perspectives is essential.

2. Callister LC, Getmanenko N, Garvrish N, et al. Giving birth: the voices of Russian women. MCN Am J Matern Child Nurs. 2007:32(1):18–24. 3. Farnes C, Callister LC, Beckstrand R, Carlton T. Healer

8

4.

5. 6. 7. 8. [AQ4]

9. 10.

11.

12.

13. [AQ5]

14. 15.

16.

17.

18.

19. 20. 21.


shopping among childbearing women of Ghana, West Africa. J Transcult Nurs. Manuscript submitted for publication. Johnson TRS, Callister LC, Beckstrand RL, Freeborn DS. Dutch women’s perceptions of childbirth in the Netherlands. MCN Am J Matern Child Nurs. 2007;32(3):170– 177. Wilkinson SE, Callister LC. Perceptions of childbearing women in the Ashanti Region of Ghana. Health Care Women Int. In press. Callister LC. Making meaning: women’s birth narratives. J Obstetr Gynecol Neonatal Nurs. 2004;33:508– 518. Emmanuel E, Creedy DK, St John W, Gamble J, Brown C. Maternal role development following childbirth among Australian women. J Adv Nurs. 2008;64:18–26. Australian Bureau of Statistics. Demographic statistics, March 2009. http://www.abs.gov/au/ausstats/abs@ .nsf/mf/3101.0. Accessed December 10, 2009. Central Intelligence Agency. The world factbook 2009. http//www.cia.gov/library/publications/the-worldfactbook. Accessed December 20, 2009. DeLange TE, Bufffe MP, Heard AR, Tuker G, Kennare R, Dekker GA. Avoidable risk factors in perinatal deaths: a perinatal audit in South Australia. Aust N Z J Obstetr Gynecol. 2008;48:50–57. Tracy SK, Sullivan E, Dahlen H, Black D, Wang YA, Tracy MB. Does size matter? A population-based study of birth in lower volume maternity hospitals for low risk women. Br J Obstetr Gynecol. 2006;113:86–96. Laws P, Abeywardana S, Walker J, Sullivan F. Australia’s Mothers and Babies. Sydney, New South Wales, Australia: Australian Institute of Health and Welfare National Perinatal Statistics Unit; 2006. United Nations Department of Economic and Social Affairs Population Division. International Migration 2006. New York: United Nations Department of Economic and Social Affairs Population Division. Carolan M. Maternal and child health nurses: a vital link to the community for primiparae over the age of 35. Contemp Nurse. 2004;18:133–142. Tracy SK, Dahlen H, Caplice S, Laws P, Wang YA, Sullivan E. Birth centers in Australia: a national population-based study of perinatal mortality associated with giving birth in a birth center. Birth. 2007;34:184–201. Robson SJ, Tan WS, Adeyemi A, Dear KBG. Estimating the rate of cesarean section by maternal request: anonymous survey of obstetricians in Australia. Birth. 2009;36:208– 212. Brown S, Darcy M, Bruinsma F. Having a baby in Victoria 1989–2000: continuity and changes in the decade following the Ministerial Review of Birthing Services. Aust N Z J Public Health. 2002;26:242–250. 3 Centres Collaboration, Victoria Maternity Project Community of Practice. Pregnancy and birth. http://www. latrobe.edu.au/mchr/[email protected]#Care%20 provided. Accessed December 10, 2009. Callister LC. How is evidence-based decision making promoted in childbearing women in Australia? MCN Am J Matern Child Nurs. 2009;34:131. Fahy K. An Australian history of the subordination of midwifery. Women Birth. 2007;20:25–29. Fenwick J, Butt J, Downie J, Monterosso L, Wood J. Prior-

22. 23. 24.

25. 26. 27. 28.

29. 30. 31. 32. 33.

34. 35. 36. 37.

38.

39. 40. 41. 42.

ities for midwifery research in Perth, Western Australia: a Delphi study. Int J Nurs. 2005;12:78–93. Freeman LM, Griew K. Enhancing the midwife-woman relationship through shared decision making and clinical guidelines. Women Birth. 2007;20:11–15. Maher J. Midwife interactions with birth support people in Melbourne, Australia. Midwifery. 2004;20:273–280. Rayner J, Forster D, McLachlan H, Yelland J, Davey MA. A state-wide review of hospital postnatal care in Victoria, Australia: the views and experiences of midwives. Midwifery. 2008;24:310–320. Dahlen HG, Barclay LM, Homer C. Preparing for the first birth: mothers’ experiences at home and in hospitals in Australia. J Perinatal Educ. 2008;17:21–32. Schneider Z. An Australian study of women’s experiences of their first pregnancy. Midwifery. 2002;18:238–249. Peart K. Birth planning: is it beneficial to pregnant women? Aust J Midwifery. 2004;17:27–29. Bayes S, Fenwick J, Hauck Y. A qualitative analysis of women’s short accounts of labor and birth in a Western Australian public tertiary hospital. J Midwifery Women’s Health. 2008;53:53–61. Walker R, Turnbull D, Wilkinson C. Increasing cesarean section rates: exploring the role of culture in an Australian community. Birth. 2004;31:117–124. Seibold C. Young single women’s experiences of pregnancy, adjustment, decision-making and ongoing identity construction. Midwifery. 2004;20:171–180. Fisher C, Hauck Y, Fenwick J. How social context impacts on women’s fears of childbirth: a Western Australian example. Soc Sci Med. 2006;63:64–75. Fenwick J, Hauck Y, Downie J, Butt J. The childbirth expectations of a self-selected cohort of Western Australian women. Midwifery. 2005;21:23–35. Hauck Y, Fenwick J, Downie J, Butt J. The influence of childbirth expectations on Western Australian women’s perceptions of their birth experience. Midwifery. 2007;23:235–247. Tobin GA, Begley CM. Methodological rigour within a qualitative framework. J Adv Nurs. 2004;48(4):388–396. Guest G, Bunce A, Johnson L. How many interviews are enough? Field Methods. 2006;18:59–82. Morse JM. Qualitative Research Methods: A Contemporary Dialogue. Thousand Oaks, CA: Sage; 1989. Morse JM, Barrett M, Mayan M, Olson K, Spiers J. Verification strategies for establishing reliability and validity in qualitative research. Int J Qualitative Methods. 2002;1:Article 2. http://www.ualberta.ca/. Accessed December 10, 2009. Dickson JE, Paech MJ, McDonald SJ, Evans SF. Maternal satisfaction with childbirth and intrapartum analgesia in nulliparous labor. Aust/N Z J Obstetr Gynecol. 2003;43:463–468. Parratt J. The impact of childbirth experiences on women’s sense of self. Aust Coll Midwives J. 2002;15:10– 16. Parratt J, Fahy K. Trusting enough to be out of control: a pilot study of women’s sense of self during childbirth. Aust Coll Midwives J. 2003;16:15–22. Callister LC, Khalaf I. Spirituality in childbearing women. J Perinatal Ed. In press. Beck CT. Birth trauma: in the eye of the beholder. Nurs Res. 2004;53:28–35.

Giving Birth

43. Goldbort JG. Women’s lived experience of their unexpected birthing process. MCN Am J Matern Child Nurs. 2009;34:57–62. 44. VandeVusse A, VandeVusse L. Reality television as a source of information about birth: the messages and their implications. J Midwifery Women’s Health. 2008;53:482. 45. Callister LC. How is evidence based decision making promoted in childbearing women in Australia? MCN Am J Matern Child Nurs. 2009;34(1):131. 46. Adams ED, Bianchi AL. A practical approach to labor support. J Obstetr Gynecol Neonatal Nurs. 2008;37(1):24– 34. 47. Declerq ER, Sakala C, Corry MP, Applebaum S. Listening to Mothers II: Report of the Second National US Survey of Women’s Childbearing Experiences. New York: Childbirth Connection; 2006. 48. Sakala C, Corry MP. Evidence-Based Maternity Care: What It Is and What It Can Achieve. New York: Milbank Memorial Fund; 2008. 49. Bryanton J, Gagnon AJ, Johnston C, Hatem M. Predictors of women’s perceptions of the childbirth experience. J Obstetr Gynecol Neonatal Nurs. 2008;37(1):24– 34. 50. Downe S, Simpson L, Trafford K. Expert intra-partum care: a meta-synthesis. J Adv Nurs. 2006;127–140. 51. Gennaro S, Mayberry LJ, Kafulafula U. The evidence sup-

52. 53. 54. 55. 56. 57.

58.

59.

9

porting nursing management of labor. J Obstetr Gynecol Neonatal Nurs. 2007;36:598–604. Kenyon S, Ulman R, Mori R, Whittle M. Care of healthy women and their babies during childbirth: summary of NICE guidelines. Br Med J. 2007;335:667–668. Zeldes K, Norsigian J. Encouraging women to consider a less medicalized approach to childbirth without turning them off. Birth. 2008;35:254–249. Redshaw M. Women as consumers of maternity care: measuring “satisfaction” or “dissatisfaction?” Birth. 2008;35:73–76. Charles J, Curtis L. Birth Afterthoughts: a listening and referral service. Br J Midwifery. 1994;2:331–334. Inglis S. Accessing a debriefing service following birth. J Midwifery. 2002;10:368–371. Rowan C, Bick D, Bastos MHDS. Postnatal debriefing interventions to prevent maternal mental health problems after birth: exploring the gap between the evidence and UK policy and practice. Worldviews Evidence Based Nurs. 2nd quarter 2007:97–105. Janssen PA, Dennis CL, Reime B. Development and psychometric testing of Care in Obstetrics: Measure for Testing Satisfaction (COMFORTS) Scale. Res Nurs Health. 2006;29:51–60. World Health Organization. Women and Health: Today’s Evidence, Tomorrow’s Evidence. Geneva, Switzerland: World Health Organization; 2009.

Title: Giving Birth: The Voices of Australian Women Authors: Lynn Clark Callister, Shelley Thacker Holt, and Melody West Kuhre

Author Queries AQ1: AQ2: AQ3: AQ4: AQ5: AQ6:

Note that this Web site could not be accessed. Please check whether the edited sentence (This cognitive . . . other women.) is OK. Please update refs. 1, 3, 5, and 41. The Web site address in ref. 8 could not be accessed. Please check. Please cite refs. 13, 14, and 56 in the text. Provide the year of publication for ref. 13. Please check whether edits in the last 2 lines of Table 2 are OK.