Karen L.Coyle RN, RM,BHlthSc(Nur), MN, FamilyBirth Centre, King EdwardMemorial Hospital, BagotRoad, Subiaco,WA,Australia 6008

Yvonne Hauck BScN,MSc, PhD, RM, EdithCowan University, Schoolof Nursing & Public Health,Pearson Street,Churchlands,WA,Australia 6018. E-mail:y.hauck@ecu.edu.au

Patricia Percival PhD,FRCNA, RN, RM,

Linda J.KristjansonMN,PhD, RN, BN, Professor,Faculty ofCommunications, Healthand Science, Edith CowanUniversity, Pearson St,Churchlands,WA,Australia 6018

(Correspondence to KC)

Received 31May 2000Revised 6 October 2000Accepted 22 February 2001Published online 6 June2001

Normality and collaboration:mothers’perceptions of birthcentre versus hospital care

Karen Coyle,YvonneHauck,Patricia Percival andLinda Kristjanson

Objective: to describewomen’s perceptions of care inWestern Australian birth centresfollowing a previous hospital birth.

Design, setting and participants: an exploratory designwas used to study the careexperiencesof17womenrecruited fromthreeWesternAustralianbirth centres.Datawereobtained fromin-depth interviews that exploredwomen’s perceptions of their care in boththe birth centre and hospital context.

Findings: four key themes emerged fromthe analysis: ‘beliefs about pregnancy and birth’,‘nature of the care relationship’,‘care interactions’, and ‘care structures’.The themes of‘beliefs aboutpregnancy andbirth’and ‘nature of the care relationship’are discussed in thispaper. Beliefs about pregnancy andbirth refer to the philosophical underpinnings ofpregnancy andbirth held by women and their carers.Nature of the care relationshipidenti¢eswomen’s perceptions of their relationshipwith health professionals.Careinteractions and care structureswill be described in a subsequent paper.

Keyconclusions and implications forpractice:Thewomen’s comments suggesteddi¡erences in philosophy between hospital and birth-centre settings.The philosophyand beliefs of caregiverswas an important component of the care experience.Womenvalued the normality of the birth-centre approach and the opportunity to experiencethe birth of their childwith collaborative support fromamidwife. & 2001HarcourtPublishers Ltd

INTRODUCTION

During the 1990s in Australia, birth-centre care

emerged as a major alternative to mainsteam

maternity services. A recent survey to determine

birth-centre practices in Australia revealed that

before 1990 there were only three birth centres

operating in Australia, compared with 24 in 1997

(Waldenstrom & Lawson 1998). The expansion

of the birth-centre option has occurred alongside

the development of other midwifery models of

care, such as team midwifery and government

funded home births. This expansion has been in

response to a number of ministerial reviews of

maternity services at both state and national

level, which recommended the development of

alternatives to mainstream services (Health

Department of New South Wales 1989, Health

Department of Victoria 1990, Health Depart-

Midwifery (2001) 17, 182^193 & 2001Harcourt Publishers Ltddoi:10.1054/midw.2001.0256, available online at http://www.idealibrary.com on

ment of Western Australia 1990, National

Health & Medical Research Council 1996). As

a result, some of the alternative models of care

developed were funded through government

schemes.

The development of birth centres has occurred

in response to concerns over medicalisation of

‘normal birth’, with the obstetric culture in

Australia being characterised by high rates of

intervention (Day et al. 1997). Care in the birth

centre context is based on the philosophy that

childbirth is a natural physiological process and

largely a social event rather than a medical one

(Matthews & Zadak 1991). Care provision

reflects this attitude with limited use of technol-

ogy and a client-centred focus, where women and

their families are involved in the decision-making

process. Continuity of care throughout the

childbearing continuum from a small team of

Normality and collaboration 183

midwives is a predominant feature. However,

this model of care is only available to women at

low obstetric risk.

In Australia a number of non-randomised

trials have compared birth-centre care with

standard hospital-based care. These findings

suggest that birth-centre care for women at low

obstetric risk results in fewer obstetric interven-

tions (Eggers et al. 1985, Bradley et al. 1990,

Linder-Pelz et al. 1990, Whelan 1994, Wood

1997) and higher rates of satisfaction (Bradley et

al. 1990, Whelan 1994, Wood 1997). A recent

systematic review by Waldenstrom and Turnbull

(1998) drew similar conclusions when assessing

models that offer continuity of midwifery care.

The only randomised-controlled trial on birth-

centre care to date, undertaken in Sweden,

confirms the findings of many Australian birth-

centre studies. In the Swedish trial, birth-centre

care when compared to standard care resulted in

significantly lower rates of intervention, such as

obstetric analgesia, induction and augmentation

of labour and electronic fetal monitoring (Wal-

denstrom et al. 1997). Higher levels of satisfac-

tion were also noted for both physical and

psychological aspects of care in the birth-centre

group (Waldenstrom & Nilsson 1994). Direct

comparison with Australian birth-centre out-

comes is difficult because of different inclusion

and transfer criteria. Operative delivery rates

reported in the Swedish trial were substantially

lower than the rates of assisted delivery reported

in birth-centre outcomes in Australia (Morris et

al. 1986, Biro & Lumley 1991, Stern et al. 1992,

Wood 1997). These low intervention rates

possibly reflect the general obstetric culture in

Sweden, which has much lower rates of inter-

vention than Australia (Waldenstrom et al.

1997).

In the Australian context a recent population

survey undertaken in Victoria found that women

who had received care in a birth centre reported

significantly more positive experiences than

women who had received care in other settings

(Brown & Lumley 1998). Findings from this

survey also suggest a strong correlation between

satisfaction and knowing the midwife prior to

labour, independent of model of care (Brown &

Lumley 1998). In contrast, further analysis of the

Stockholm birth-centre trial indicated that a

known versus unknown midwife carer in labour

had no impact on the reported levels of satisfac-

tion in the birth centre arm of the trial

(Waldenstrom 1998). The researchers concluded

that the high levels of satisfaction with birth

centre care may be related more to attitude and

philosophy of carers and the setting rather than a

personal relationship with a particular midwife

(Waldenstrom 1998).

Research to date, on the birth centre model of

care, has focused largely on clinical outcomes to

establish safety. Assessment of satisfaction with

this model of care has had more limited

investigation. Satisfaction has been assessed

quantitatively in a number of studies, indicating

that women are more satisfied with birth-centre

care compared with standard care (Waldenstrom

& Nilsson 1994, Wood 1997). At the time of this

study, women’s perceptions of care in the

Australian birth-centre setting had not been

studied in relation to previous hospital care.

Additionally, the focus of the study was on

women’s perceptions of the care they received,

not on their actual birth experience.

METHOD

An exploratory design was chosen for this study

to enable the principal investigator to explore

women’s perceptions of the care they experienced

in both birth centre and hospital settings. A

qualitative approach was used to document and

interpret this phenomenon, where little is known,

from an emic perspective (Patton 1990, Morse &

Field 1995, Creswell 1998, Strauss & Corbin

1998). This perspective allowed exploration of

women’s perceptions of care beyond assessing

satisfaction levels and revealed aspects of care

that were important to mothers. A modified

grounded theory approach was adopted to guide

this study. This inductive research approach

involved a constant comparison technique that

allowed the important categories and themes to

emerge from data without prior assumptions

(Strauss & Corbin 1998).

Following approval by the university and

hospital ethics committees, a convenience sample

of women from all three Western Australian

birth centres was selected. In one birth centre,

women who met the selection criteria were

invited to participate, by a midwife not involved

in the study, prior to their discharge. Women in

the other two birth centres were recruited from a

larger cohort of mothers participating in a

longitudinal birth study in Western Australia

(conducted by Dr P Percival). Those women who

met the selection criteria for the present study

were approached over the telephone by the

principal investigator and invited to participate.

The inclusion criteria were utilised for all three

birth centres and ensured that women inter-

viewed had received care from a known midwife

during their labour and birth, an important

feature of this model of care. These criteria

excluded first-time mothers who had not experi-

enced hospital care. To be invited to participate

in the study, women:

. attended a minimum of five antenatal visits by

birth-centre midwives during their pregnancy;

184 Midwifery

. had a midwife care for them in labour who had

conducted at least two of their antenatal visits;

. experienced a normal birth;

. had been discharged home within 24 hours of

the birth;

. had previously given birth to a baby in a

hospital setting;

. were available for interview two to four

months after the birth of their baby;

. had not had any part of their pregnancy care

provided by the principal investigator.

Sample size was not pre-determined and inter-

viewing continued until saturation occurred,

meaning no new information was being revealed

(Patton 1990, Morse 1995). Twenty-one women

were invited to participate in the study, four

declined the offer and saturation was achieved

after 17 interviews. Interviews took place be-

tween November 1996 and April 1997 in the

women’s own homes at two to four months

postpartum by the principal investigator and

lasted between 45 and 90 minutes. The

decision to wait for this time period postpartum

was to allow women to recover from the

birth physically and overcome early postpartum

problems. The immediate postpartum period

was also avoided to reduce the ‘halo effect’

(Lumley 1985, Bramadat & Driedger 1993) on

the woman’s most recent birth experience. Face-

to-face interviews in the women’s homes facili-

tated a more comfortable, relaxed environment

that enhanced participant disclosure. In addi-

tion, as all participants had a new baby and at

least one other child, it was easier and more

convenient for the interviewer to travel to the

mother.

The investigator explored women’s percep-

tions of both their most recent care experiences

and previous hospital experiences. A semi-

structured interview guide with open-ended

questions and prompts was developed to provide

a general outline for the interviews. This guide

was not rigidly adhered to, allowing the inter-

viewer to explore issues as they emerged (Mini-

chiello et al. 1995). The open-ended questions

and prompts evolved through a review of the

literature and consultation with a number of

midwives with research expertise.

Data were analysed from written narrative

communication transcribed from interviews. The

units of analysis were phrases, sentences or

paragraphs (Strauss & Corbin 1998). Significant

meanings of these units were then coded and

categorised into groups. This form of analysis is

referred to as latent content analysis as it allows

for the underlying meanings within the commu-

nication to be identified within the context of the

entire interview (Field & Morse 1990). Analysis

began and continued throughout the interview

process. Each interview was transcribed as soon

as possible after the interview and coded

throughout the data-collection period. Steps

used for data analysis were modified slightly

but were based on the method outlined by

Burnard (1991):

1. Audiotapes were transcribed verbatim;

2. Each typed transcript was checked against the

audiotape;

3. The written transcripts from each interview

were read and keywords and significant

statements were highlighted throughout the

transcript;

4. Transcripts were read again and emerging

themes were listed in the margins of the

recorded data to describe all aspects of the

content thereby allowing the investigator to

become immersed in the data;

5. Similar themes were grouped together;

6. Themes were named to reflect the contents;

7. Transcripts were then re-read alongside the

final list of themes, identifying which theme

each significant statement belonged to.

Several steps were undertaken to confirm the

credibility, fittingness, and auditability of the

findings. Co-researchers read interview tran-

scripts and compared their interpretations with

the principal investigator’s category system.

Further validation of the findings was achieved

by returning to two of the participants who were

invited to make comments on the interpretation

and categorisation of the data. Feedback from

these participants confirmed that the investiga-

tors had interpreted the data correctly and major

themes were a true reflection of the women’s care

experiences. Auditability is achieved when a

reader can follow the progression of events the

investigator used during the research process

(Sandelowski 1986). The principal investigator

documented an audit trail throughout the data

analysis to demonstrate how categorisation was

determined. This was reviewed and confirmed

with the research team.

Limitations associated with this study are that

the sample was self-selecting, clients eligible for

the study chose birth-centre care and by the

nature of the selection criteria achieved an

uncomplicated birth. Being influenced by such

birth experiences may have limited the variability

of data and influenced analysis of theme dimen-

sions. Although findings may not be generalised

to all childbearing women, discussion of simila-

rities between findings and theory can enhance

vertical generalisability (Johnson 1997). Addi-

tionally, thick description promotes understand-

ing of the context of findings, thus allowing the

reader to assess whether findings fit similar

contexts where women receive care in other

Australian birth settings.

Fig. 1 Women’s perceptions of birth-centre versus hospitalcare; ‘beliefs about pregnancy and birth’ and ‘nature of thecare relationship’ addressed in this paper

Normality and collaboration 185

FINDINGS ANDDISCUSSION

All seventeen participants in this study experi-

enced at least one of their previous pregnancies

within a hospital setting, with one participant

also undergoing a previous home birth. All but

one participant had achieved a normal vaginal

birth in their previous hospital experience.

Sixteen women were of Caucasian background

and one woman was of Maori background. All

participants had a current partner. Participants’

ages ranged from 22 to 34 years with the number

of children varying from two to five. The socio-

economic level of the families varied across an

income level of less than $20 000 to greater than

$50 000. The participants represented a broad

range of income levels as the 1996 census for

Western Australia revealed that the median

household income was $34 000 (Australian Bu-

reau of Statistics 2000). Eight women had

completed high-school requirements and the

remaining nine participants achieved a post-

secondary qualification. Seven women described

their occupation as being in the service industry,

five as professionals and a further five solely

involved with home duties.

Women interviewed in this study shared their

experiences of care in both the hospital and

birth-centre settings and provided a wealth of

data about two different models of care. Final

analysis of the data resulted in the identification

of four key themes: ‘beliefs about pregnancy and

birth’; ‘nature of the care relationship’; ‘care

interactions’; and ‘care structures’. Each one of

these themes comprised two dimensions at either

end of a continuum, as outlined in Figure 1. The

themes ‘beliefs about pregnancy and birth’ and

the ‘nature of the care relationship’ are discussed

in this paper. The remaining themes are pre-

sented in a subsequent publication. Verbatim

quotes from participants were used to illustrate

themes extracted from the data. Each participant

was interviewed once. A pseudo name is

presented following each quote and information

is given regarding parity, for example [Ann, 2nd

baby].

Beliefs about pregnancy andbirth

The first theme to emerge from the data was

‘beliefs about pregnancy and birth’. This theme

referred to the participants’ attitudes and beliefs

about pregnancy and the birth process. The

beliefs identified within the data varied along a

continuum from birth being perceived as

a normal life event to birth being viewed as a

disease process. The features of each of these

beliefs are outlined below. An exemplar of this

theme is presented in Box 1.

Birth as a normal life event

All participants believed that birth was a normal

life event. Interpretations of the carers’ beliefs

were also revealed in women’s descriptions of the

care they received. This dimension comprised

two features. These were (a) birth as a natural

process and (b) carers’ non-interventionist ap-

proach.

Birth as a natural process

This feature was defined as the belief that

pregnancy and labour were normal processes.

Many participants expressed their belief that

birth was not an illness and, therefore, should

not be treated as such:

Giving birth is not an illness, it is not a

medical procedure, it is life, it is a miracle and

each and every one is different and I think

people have lost that, or had lost, I feel it is

coming back now, I think women are coming

into their own about how they want to give

birth... [Maxine, 4th baby]

Women felt that the midwives treated preg-

nancy and birth as a natural life event in that

they actively encouraged women to listen to their

bodies and trust in their ability to birth naturally:

. . . she [midwife] said you know how to do it,

your body knows how to do it. The baby is

going to come out. She gave me the

186 Midwifery

confidence to know it was going to be fine.

[Mary, 2nd baby]

Carer’s non-interventionist approach

The midwife’s approach to care during preg-

nancy and labour was seen as one of non-

interference. This approach reflected the belief

that birth was a normal life event.

Participants’ experiences revealed that the

birth-centre midwives did not interfere with

their bodies in a physical sense. Procedures

such as vaginal examinations were kept to a

minimum and used when required rather than

routinely:

I wasn’t touched when I came in and I was in

labour, I wasn’t examined at all which I really

appreciated. They seemed to know where I

was at and not interfere with me in any way.

[Vivian, 3rd baby]

Women also felt the birth-centre midwives’ non-

interventionist approach and support of natural

childbirth was enhanced by the fact that technol-

ogy such as epidurals and continuous electronic

fetal monitoring were not readily available in the

birth centre. Participants considered this fact

when choosing where to have their child:

. . .the fact if I said in labour I wanted an

epidural there wouldn’t be a doctor there

straight away to say, ‘OK let’s give you an

epidural, don’t worry you shouldn’t have to

have pain’. Just to have someone there to say,

‘No let’s go a bit longer, you can do this’.

[Kathy, 4th baby]

Birth as a disease process

Participants felt that many health professionals in

hospital settings held the belief that birth was a

disease process. This dimension comprised the

following features: (a) birth is viewed as an illness

and (b) carer’s interventionist approach.

Birth viewed as an illness

The belief that pregnancy and labour were not

regarded as normal processes was evident in

women’s descriptions of interactions with carers

in the hospital setting. Most women had

previous contact with doctors during routine

pregnancy and birthing care, and felt that

doctors’ attitudes reflected their medical back-

ground in that pregnancy and birth were viewed

as a disease with many potential dangers. One

participant indicated that midwives within the

Box 1 Exemplar of theme: Beliefs about pregnancy and birth

Beliefs about pregnancy andbirth

This theme captures the attitudes and beliefs about the pregnancy and birth process held by bothwomen and their carers

Dimension: birth as a normal life eventBirth perceived as a normal life event.

Features Def|nition Exemplar1.Birth as a naturalprocess

The belief that pregnancyand birth are normal life experiences.

‘. . . theway they [midwives] just seemedto treat birth as being a natural processinstead of a medical process’[Mary, 2nd baby].

2.Carer’s non-interventionistapproach

The lack of physical interferencewith the birth process.

‘. . . themidwives would feelmy stomachand that was it.They put themonitor[doptone] on and listened to the baby.They didnot want to interfere in any way’ [Susy, 2nd baby].

Dimension: birth as a disease processBirth viewed as a disease process.

Features Def|nition Exemplar1.Birth viewed asan illness

The belief that pregnancy andbirth are pathological processes.

‘Doctors don’t talk about things youcan do during labour.When you seea doctor they talk aboutwhat problemsyoumay have andwhatmight gowrong.They don’t talk aboutwhat is normaland how you canmake things be normal’[Carol, 2nd baby].

2.Carer’s interventionistapproach

The physical interferencewith the birth process.

‘She [Obstetrician] never really spokeabout the actual birth. She didmentionepidurals and how I would feel abouthaving one. I said I’d prefer not tohave one.But as far as the birth itselfthat was all that was done’[ Jodi, 2nd baby].

Normality and collaboration 187

hospital system also adopted these beliefs and

focused upon preparing women for possible

interventions:

Actually I found the first time we went to

antenatal classes it was like that. My husband

and I walked out in shock . . . For example,

they [midwives] talked about drugs but they

didn’t talk about how you can control your

pain without this. They focused on

intervention, what would happen if you had

to have a caesarean, what would happen if

you needed stitches. I think it is important to

say these things may happen but they

shouldn’t be the focus. [Carol, 2nd baby]

Carer’s interventionist approach

The carer’s orientation to pregnancy and labour

was characterised by interference when they

adopted the belief that birth was a disease

process. The perception that doctors did not

view birth as a normal life event was endorsed by

the fact that the doctor was seen to adopt an

invasive approach. Procedures such as vaginal

examinations were often performed in pregnancy

as routine. As one participant stated ‘. . .with the

doctors, they wanted to do internals and check

me all the time’ [Susy, 3rd baby].

In the hospital setting the use of technology

was an accepted part of the birth process. Many

participants perceived that there was an assump-

tion that women would want to use analgesia,

such as epidurals. One participant recalled her

labour experience within a hospital. She felt that

she was coping well, and yet heard the midwives

discussing her eligibility for an epidural:

When I was in the hospital, when I was

actually in labour, a midwife said ‘it is too late

to give her an epidural’ and I thought, ‘well,

did I ask for one?’ [Vivian, 3rd baby]

Overall, women perceived that birth-centre mid-

wives’ practice supported their own beliefs in the

normality of birth. A midwives’ ‘hands off’

approach was positively received by women and

reinforced their belief that birth was a normal life

event. However, during their previous hospital

experiences, women did not feel that their carers

trusted the birth process. The messages given by

carers was that birth was safer in hospital.

Moreover, the preparatory discussions with wo-

men for interventions made women feel that

carers believed intervention was expected: this

interventionist approach resulted in women per-

ceiving that technology was an integral part of the

birth process in the hospital setting. These

findings suggest that the midwife’s philosophy

may be influenced by the health-care organisation

in which care is provided and raise questions

about the extent to which the institution’s

philosophy influences their individual practice.

Other research has also found that care

provision in birth centres was based on the

attitude that birth was a normal life event

(Mathews & Zadak 1991). This is in contrast to

the ‘interventionist’ approach to care that

women in the present study described in the

hospital context. This ‘illness’ ideology suggests

that care delivery within mainstream maternity

services remains embedded in the medical model

(Wagner 1994, Bennett 1997). Additionally, a

Swedish study also found that the mechanistic

and medicalised understanding of childbirth

dominated the discourse within midwifery clinics

although a second smaller theme relating to

natural childbirth also emerged (Olsson et al.

2000).

Bryar (1995) also suggested that the care

context has a great impact on the type of care

midwives were able to deliver and argued that

the midwife’s role has developed in a medical

way because of the organisational setting. Find-

ings from the current study provide further

evidence to support Bryar’s argument. Midwif-

ery care in the two care settings was perceived

differently by women suggesting that the mid-

wife’s behaviour may be shaped by the social

forces and policies of the institution in which

they practice.

Other researchers who have evaluated mid-

wifery models of care have also questioned the

constraints of the institution on midwives’

practice. In their evaluation of one-to-one

midwifery practice, McCourt and Page (1996)

questioned whether midwifery-led care was

possible within an obstetric-led unit. Evaluation

of the one-to-one scheme, when compared to

traditional obstetric care did not result in a large

increase in rates of normal birth as anticipated.

The researchers concluded that the midwife’s

practice in the hospital setting was constrained

by obstetric-biased policies and practices that do

not support the normality of the physiological

processes of labour and birth.

Findings from the only randomised controlled

trial on birth-centre care carried out in Sweden,

also suggested that birth-centre philosophy and

policies not only affected carers, but also

women’s behaviour (Waldenstrom & Nilsson

1994). Prior to this trial, the low rates of

intervention reported in the birth-centre setting

were attributed largely to selection bias; that is

women who chose birth-centre care were more

committed to natural birth than women who

chose hospital care. The Swedish trial addressed

this selection bias limitation in that all women

who participated in the study expressed an

interest in natural childbirth and were keen to

receive birth-centre care. The researchers found

that women who received birth-centre care

used significantly less pain relief than women in

the mainstream system. These findings raised

188 Midwifery

awareness about other aspects of care that

influenced women’s experiences and suggested

that the philosophy of carers and birth-centre

policies played a major part in influencing

women’s behaviour.

However, others researchers have suggested

that midwives were able to practice from a

midwifery philosophy, within the hospital set-

ting. A recent randomised controlled trial of a

midwifery model of care for women at low

obstetric risk operating within the tertiary care

setting in Canada, found significantly lower rates

of intervention when women received midwife

care, without compromising safety (Harvey et al.

1996). This study indicated that, although care

delivery continued within the hospital system,

midwives were more selective in their use of

technology (Harvey et al. 1996).

We must emphasise that comparisons of the

success of midwifery models of care in different

countries are difficult. The obstetric culture in

Canada varies greatly to that in the UK, in terms

of the involvement of midwives in mainstream

care and the rates of intervention. The impact of

midwifery care in Canada may be greater

because of the limited involvement of midwives

in the mainstream health-care system in that

country. Additionally, the degree of autonomy

the midwives are afforded in each scheme is also

difficult to compare.

We feel, however, that regardless of the

country of setting, women want midwives to

believe that birth is a normal life event. A recent

Western Australian study into women’s home-

birth experiences highlighted this issue (Morison

et al. 1999). This phenomenological study of

couples’ home-birth revealed a strong belief by

parents that birth was a normal process and

women were capable of giving birth naturally at

home. Women who had chosen to birth at home

reported that they actively sought a midwife who

shared their philosophy of birth.

Hutton (1994) also argued that women want

midwives to believe in the woman’s ability to

give birth without intervention. However, on a

policy rather than individual level, the Winterton

report (House of Commons Health Committee

1992) initiated the process of change in the UK

by questioning the indiscriminate use of technol-

ogy during pregnancy, labour and birth.

Nature of the care relationship

This theme entitled the ‘nature of the care

relationship’ was defined as women’s perceptions

of the type of relationships they had with care

providers. Women identified that the relation-

ship with health providers varied from one of

collaboration to a provider-dominated relation-

ship. Moreover, the nature of the relationship

between women and carers had a direct impact

on the degree of control women felt they had

during their birth and the corresponding

degree of satisfaction with the birth. The

features of this continuum will be explored

separately. An exemplar of this theme is pro-

vided in Box 2.

Collaborative relationship

A collaborative relationship was defined as a

partnership between the woman and her carer

and was found more often in the birth-centre

setting. This relationship was characterised by

two features: (a) equality with carers and (b)

women as primary decision-makers.

Equality with carers

The feature of equality with carers was defined as

an egalitarian relationship between the women

and carer. The relationship with the midwife

carers in the birth centre was perceived by

women to be one of equal status:

She [midwife] would come to my house, give

me my checks. We would talk on an even.

There was no superiority there and she

actually taught me how to give birth.

[Maxine, 4th baby]

Many women cared for in the birth centre said

that discussions during pregnancy revolved

around their wishes and preferences for birth;

they identified a sense of mutual respect between

themselves and the midwives providing care:

The birth-centre births were the more positive

two experiences because I really felt my

choices would be respected. What I wanted

to do would be listened to and would be

supported. [Kathy, 4th baby]

Women as primary decision-makers

The feature of women as primary decision-

makers was defined as women taking responsi-

bility for decisions related to their care. Women

who accessed birth-centre care felt that they were

treated as autonomous individuals; the midwife

provided them with information that enabled

them to make informed decisions:

She [midwife] would ask me a question and

say we could do it [manage labour] this way

and that way and gave me suggestions, but

ultimately it was my decision. [Bridgit, 2nd

baby]

Women acknowledged that they were able to

make decisions appropriate for them. One

participant outlined how the birth-centre mid-

wife had recommended transfer into the hospital

for a longer postpartum stay because of a large

postpartum haemorrhage after her birth. This

Normality and collaboration 189

woman considered the advice, but opted to go

home to recover:

I chose to go home and that was respected as

well. I wasn’t made to go into hospital. As it

turned out that was totally appropriate for

me, I recovered quickly. [Vivian, 3rd baby]

Provider-dominated relationship

A provider-dominated relationship was defined

as a paternalistic relationship between the

woman and her carer. Many participants, when

describing their interactions with health profes-

sionals in the hospital setting, identified a sense

of medical domination in the relationship. This

type of relationship was composed of two

features: (a) health professional superiority and

(b) women as passive participants.

Health professional superiority

This feature was defined as the authoritarian

stance adopted by carers when interacting with

women. Many participants felt that medical

practitioners and midwives in the hospital setting

had a superior attitude because they were the

experts.

One woman shared her experience of birthing

in the birth centre and then being transferred

into the hospital because her baby required

phototherapy. Her relations with carers changed

from one of equality to one of feeling dominated:

I ended up being admitted to the main unit for

a day with him [baby] . . . . There wasn’t that

respect that I knew my body and I knew what

I needed and didn’t need. It was back to more

of ‘we know what’s best for you’ sort of

attitude and ‘we know what’s best for baby’.

It was very different. [Kathy, 4th baby]

Many women felt they had no voice when they

had doctor care, as one woman shared:

When I had a doctor it was his baby, we

weren’t allowed to talk and I had to do it his

way. [Susy, 3rd baby]

This resulted in women feeling dominated by the

health professional and had a negative effect on

their care perceptions.

Some carers who functioned within the hospi-

tal setting were perceived to impose their own

beliefs on women. When participants did not

want to follow medical advice, they often felt

Box 2 Exemplar of Theme:Nature of the care relationship

Nature of the care relationship

How women perceive their role in the relationshipwith the health professionals that provide care.

Dimension: collaborative relationshipThe collaborative relationship between thewoman and her carer.

Features Def|nition Exemplar1. Equality withcarer

An egalitarian relationship between thewoman and carer.

‘They encouragedme to express whatever I feltI would like.They put a lot of care intowhat Iwould like for the birth, who I would like to bethere . . . even the very small details and thatreallymeant a lot to me’ [Bridgit, 2nd baby].

2.Women asprimary decisionmakers

Women taking responsibility for decisionsrelated to their care.

‘She [midwife] was the onewho had no personalstatement, shewas objective. She could seewewere getting a lot of pressure and shewas theonewho kept bringing it back and saying, holdon, you have two options’ [Carol, 2nd baby].

Dimension: provider dominated relationshipThe paternalistic relationship between thewoman and her carer

Features Def|nition Exemplar1.Healthprofessionalsuperiority

The authoritarian stancecarers adopt when interactingwith pregnantwomen.

‘I found themales [doctors], although they werevery nice people and could be great at otherthings, but when it comes to something likegiving birth. I found their attitudes very ‘theyknowbetter’.That o¡endedme as awomanandmother. . .’ [Maxine, 4th baby].

2.Women as passiveparticipants

Women’s lack of involvementin decisions relatedto their care.

‘The only timewe had problems was towards theendwhen our obstetricianwas concernedwiththe baby’s weight. I felt the control got takenawayfromus a bit by everybody. . .Themidwivesthen said if the obstetricianwon’t agree to it wewon’t let you into the birth centre, we shallthrow you out. . . They weren’t saying wewill talk about this and decide together,it was whatever the obstetrician says iswhat goes’ [ Jodi, 2nd baby].

190 Midwifery

pressured to conform to the carer’s view, rather

than the carer respecting the women’s choices.

One woman felt strongly about her baby not

being given a vitamin K injection after birth and

had discussed this with the doctor at a routine

antenatal visit. This woman described how

immediately after birth, in the birth centre, the

doctor continued to pressure her to consent to

vitamin K:

The doctor hovered up and down the hallway

and when he heard the baby cry, he came in.

But once again, as soon as he came in I got

the vitamin K issue all over again, and we

were still attached to the umbilical cord and

then it happened again and it was like, ‘hang

on a minute, let me complete my birth, my

child is beautiful, he is healthy and happy,

you even said that – don’t start telling me I

have to start putting something artificial,

synthetic in his little body already’. [Maxine,

4th baby]

This woman never perceived that her doctor

accepted her right to decline treatment based on

her own belief system.

Women as passive participants

This was defined as women’s lack of involvement

in decisions related to their care. In the hospital

setting, women did not perceive that they were

encouraged to be involved in decisions affecting

their care. Women often indicated that they were

not given any choice in terms of what care they

would receive, they were simply told what would

happen:

And they didn’t seem to take any

consideration of my feelings or what I

wanted or asked me what I wanted, they

just went ahead and did it. They said ‘this is

what we have to do, this is what we are

doing’. It wasn’t, ‘this is what we could do, we

have other options’. They didn’t give me any

options. [Ruth, 2nd baby]

It was also the perception of many women that

their preferences were not accommodated. This

was in contrast to what they had expected:

At the hospital, when they had their antenatal

classes, they said you could basically have the

baby any way you wanted and I was in the

actual position I wanted but then they

wouldn’t allow me to do it. [Sharon, 2nd

baby]

Many women stated that the involvement of

doctors in pregnancy care often resulted in the

doctor having total control over any decisions.

Some participants felt that the medical staff did

not provide full information so that they could

make an informed choice. One woman, who was

advised to have labour induced after her waters

had broken, indicated that the doctor failed to

explain what this would entail. As she describes,

‘but I was never really sat down and said that

when we induce this is what is going to happen’

[Mary, 2nd baby]. This failure to provide women

with enough information also resulted in women

sensing a lack of involvement in the decision-

making process.

Overall, when women discussed their birth-

centre experience they used the midwife as a

resource but also identified that they felt they

were the primary decision-makers. This percep-

tion of choice and the acknowledgement of the

women’s right to make decisions resulted in the

care relationship being one of collaboration. The

collaborative nature of this relationship that

women perceived they had with carers supported

the ‘partnership’ model, described by Guilliland

and Pairman (1995). The theoretical concepts

underpinning this model include individual

negotiation, continuity of midwifery care, and

equal status of both woman and midwife within

the relationship (Guilliland & Pairman 1995,

Pairman 1998).

Other researchers have discussed such colla-

borative relationships between women and mid-

wives. As early as 1984, Campbell defined skilled

companionship as ‘being with’ rather than ‘doing

for’. More recently, Fleming’s (1998) conceptual

model of midwifery practice identified the nature

of midwifery from women’s perspective and

highlighted that midwives were ‘being for’ them

(p. 140). Kirkham (1996) also feels the midwives’

role in supporting the mother is an enabling one.

She defined the ideal relationship as one of

equality that encouraged good communication.

Moreover, such relationships aim to give care

within an equal partnership and avoid commu-

nications that reinforce power differences (Kirk-

ham 1993). Similarly, Kitzinger (1991) discussed

the midwives’ professional role as one that does

not dominate or direct.

Participants in Fenwick’s (1997) phenomeno-

logical study reported that ‘care took place

within a shared equal relationship between

mother and midwife’ (p. 207). Women in

Fenwick’s study had received care throughout

the pregnancy continuum from one primary

midwife carer and the place of birth varied from

home through to hospital. More recently, in her

New Zealand study Pairman (1998) also found

that women and midwives contributed equally to

the relationship.

In a phenomenological study undertaken by

Berg et al. (1996) in Sweden, women identified

the importance of being respected as an equal in

the relationship with their caregiver. This equal

working relationship between midwife and wo-

man has also been identified as an important

component of a home birth (Morison et al.

1999). Women in Morison’s study reported that

Normality and collaboration 191

their relationship with carers was based on

mutual respect. Within this relationship, women

identified that the midwife was utilised as a

resource; information was shared, concerns

discussed, and decisions negotiated. The benefits

of such collaborative relationships as those

found in the present study is perhaps best

summed up by women in Oakley’s (1989)

research who felt ‘we have performed a miracle

together’ (p. 220).

For women in the present study, a collabora-

tive relationship with carers ensured that they

had access to the information they needed to

make decisions and feel in control. Additionally,

respect and support for their choices and

decisions had a positive effect on women’s care

experiences. Conversely, failure to provide wo-

men with enough information resulted in them

feeling a lack of involvement in the decision-

making process. This lack of input into their care

often resulted in dissatisfaction with care. These

findings support those of other researchers who

have investigated satisfaction issues. For exam-

ple, Fenwick (1997) found that relationships with

carers facilitated information sharing, choices,

and control regardless of the birthing setting.

Lavender et al.’s study (1999) revealed themes of

support, information, decision making and con-

trol as contributing to women’s views of a

positive birth experience. In Morison et al.’s

(1999) home-birth study, this type of relationship

facilitated empowerment and enabled women to

control their own health. Women in Berg et al.’s

(1996) study articulated that control was

achieved by being involved in decision making

facilitated by the midwife’s support and gui-

dance. A grounded theory study by Walker and

colleagues (1995) explored women’s experiences

of midwife-led care and also reported control as

an important issue for women. The core category

to emerge in this study was the balance of

personal control and support. Personal control

was dependent upon women having options that

allowed choice, adequate information, and in-

volvement in the decision-making process.

The issue of control was also raised in a British

study by Green et al. (1990) which assessed the

relationship between women’s preferences, ex-

pectations, experiences, and subsequent feelings.

Findings from this study suggested that the issue

of control was not limited to involvement in

decision making, but was more broadly related

to the type of relationships that women believed

they had with staff. As in the present study, loss

of control was linked to factors such as lack of

information and perceptions of staff as unsup-

portive. Researchers have also found that

women were passive rather than active partici-

pants, particularly during labour, if they did not

have access to adequate information (McKay &

Yager Smith 1993, Lovell 1996).

One of the critical issues, then, in women

feeling in control is their access to adequate

information. It is important that midwives give

women information that is both evidence-based

and free of their own bias. Oakley (1993)

emphasised the importance of giving non-biased

information: ‘. . . giving them information about

their situation rather than stories about what

other people would like their situation to be’ (p.

187). Harding (2000) argued that ‘in order to

facilitate informed decision-making, women re-

quire their midwives to provide information that

is objective, evidence-based, and unswayed by

emotion and ideologies’ (p. 93). However, Hard-

ing (2000) acknowledged the experiences of the

15 midwives in her recent study who found it

difficult to present information in an impartial

manner without using subtle clues that rein-

forced their own opinions and beliefs.

CONCLUSION

The exploratory nature of this study allowed the

exploration of women’s perceptions of care

received in the birth centre setting and how this

care differed from care previously received in the

hospital setting. This study has provided insights

into women’s perceptions of the care they

received in both hospital and birth-centre set-

tings. Findings suggested that carers’ behaviours

varied depending upon the care context in which

they practised. Participants seldom perceived a

normal birth philosophy when care was received

in the hospital context. These findings also

revealed that one of the major factors influencing

women’s perceptions of control over their

pregnancy and birth was the nature of the

relationship between women and their carers.

Women who had a collaborative relationship

with their midwife indicated a sense of control

over their experience. These findings have

important implications for midwives who have

the opportunity to enhance women’s experiences

by engaging in an egalitarian relationship with

them as opposed to a dominating one.

ACKNOWLEDGEMENTS

The authors would like to acknowledge the generous

financial assistance provided by the Nurses Board of

Western Australia, Edith Cowan University and the Olive

Anstey Nursing Fund who supported this study.

REFERENCES

Australian Bureau of Statistics 2000 1996 Census of

population and housing. Online. Available: http://

www.abs.gov.au

Bennett MJ 1997 The more things change, the more they

stay the same: Whither Midwifery. Australian College

of Midwives Incorporated Journal 10: 4–14

192 Midwifery

Berg M, Lundgren I, Hermansson E et al. 1996 Women’s

experience of the encounter with the midwife during

childbirth. Midwifery 12: 11–15

Biro M, Lumley J 1991 The safety of team midwifery: the

first decade of the Monash Birth Centre. The Medical

Journal of Australia 155: 478–480

Bradley BS, Tashevska M, Selby JM 1990 Women’s first

experiences of childbirth: Two hospital settings

compared. British Journal of Psychology 63: 227–237

Bramadat IJ, Driedger, M 1993 Satisfaction with child-

birth: theories and methods of measurement. Birth 20:

22–29

Brown S, Lumley J 1998 Changing childbirth: lessons

from an Australian survey of 1336 women. British

Journal of Obstetrics & Gynaecology 105: 143–155

Bryar RM 1995 Theory for midwifery practice. Macmillan

Press Ltd, London

Burnard P 1991 A method of analysing interview

transcripts in qualitative research. Nurse Education

Today 11: 461–466

Campbell A 1984 Moderated love: a theology of profes-

sional care. SPCK, London

Creswell JW 1998 Qualitative inquiry and research design.

Sage Publications, London

Day P, Lancaster P, Huang J 1997 Australia’s

mothers and babies. AIHW National Statistics Unit,

Sydney

Eggers TR, Kloss M, Neil J et al. 1985 Family births at the

Royal Women’s Hospital, Melbourne. Australian and

New Zealand Journal of Obstetrics and Gynaecology

25: 255–258

Fenwick J 1997 The meaning of midwifery care: a

hermeneutic inquiry. Proceedings of the Australian

College of Midwives 10th Biennial National Con-

ference, Melbourne

Field AF, Morse JM 1990 Nursing research: the applica-

tion of qualitative approaches. Chapman & Hall,

New York

Fleming VE 1998 Women-with-midwives-with-women: a

model of interdependence. Midwifery 14: 137–143

Green JM, Coupland BA, Kitzinger J 1990 Expectations,

experiences & psychological outcomes of childbirth: a

prospective study of 825 women. Birth 17: 15–24

Guilliland K, Pairman S 1995 The midwifery partnership:

a model for practice. New Zealand College of

Midwives Journal October: 5–9

Harding D 2000 Making choices in childbirth. In: Page L

(ed.) The new midwifery science and sensitivity in

practice. Churchill Livingstone, London

Harvey S, Jarrell J, Brant R et al. 1996 A randomised

controlled trial of nurse-midwifery care. Birth 23:

128–135

Health Department of New South Wales 1989 Maternity

Services in New South Wales. Ministerial Task

Force on Obstetric Services in New South Wales,

Sydney

Health Department of Victoria 1990 Having a Baby in

Victoria. Final Report of the Ministerial Review of

Birthing Services in Victoria, Melbourne

Health Department of Western Australia 1990 Report of

the Ministerial Task Force to Review Obstetric

Neonatal and Gynaecological Services in Western

Australia. Volume 1. Summary and Recommenda-

tions

House of Commons Health Committee 1992 Maternity

Services Vol 1. The Winterton Report. HMSO

London

Hutton E 1994 What women want from midwives. British

Journal of Midwifery 2: 608–611

Johnson JL 1997 Generalisability in qualitative research:

Excavating the discourse. In: JM Morse (ed.)

Completing a qualitative project: details and dialogue.

Sage, London

Kirkham M 1993 Communication in midwifery. In:

Alexander J, Levy V, Roches S (eds.) Midwifery

practice: a research based approach. MacMillan,

Basingstoke

Kirkham M 1996 Professionalism past and present: with

women or with the powers that be. In: Kroll D (ed)

Midwifery care for the future: meeting the challenge.

Balliere Tindall, London

Kitzinger K 1991 Homebirth: the essential guide to giving

birth outside of the hospital. Macmillan, Canada

Lavender T, Walkinshaw SA, Walton I 1999 A prospec-

tive study of women’s views of factors contributing to

a positive birth experience. Midwifery 15: 40–46

Linder-Pelz S, Webster MA, Martins J et al. 1990

Obstetric risks and outcomes: birth centre compared

with conventional labour ward. Community Health

Studies XIV(1): 39–46

Lovell A 1996 Power and choice in birthgiving: some

thoughts. British Journal of Midwifery 4: 268–272

Lumley J 1985 Assessing satisfaction with childbirth. Birth

12: 141–145

Mathews JJ, Zadak, K 1991 The alternative birth move-

ment in the United States: history and current status.

Women & Health 17: 39–56

McCourt C, Page L (eds) 1996 Report on the evaluation

of One-to-One midwifery. Thames Valley University,

London

McKay S, Yager Smith S 1993 What are they talking

about? Is something wrong? Information sharing

during the second stage of labour. Birth 20: 140–147

Minichiello V, Aroni R, Timewell E et al. 1995 In-depth

interviewing 2nd ed. Longman, Melbourne

Morison S, Percival P, Hauck Y et al. 1999 Birthing at

home: the resolution of expectations. Midwifery 15:

32–39

Morris N, Campbell J, Biro M et al. 1986 Birth centre

confinement at the Queen Victoria Medical Centre:

four years’ experience. The Medical Journal of

Australia 144: 628–630

Morse JM 1995 The significance of saturation. Qualitative

Health Research 5: 147–148

Morse JM, Field AF 1995 Qualitative research methods

for health professionals 2nd ed. Sage Publications,

London

National Health and Medical Research Council 1996

Options for Effective Care in Childbirth for effective

care in childbirth. Australian Government Publishing

Service, Canberra

Oakley A 1989 Who cares for women. Midwives

Chronicle 102: 214–221

Oakley A 1993 Essays on women, medicine and health.

Edinburgh University Press, Edinburgh

Olsson P, Jansson L, Norberg A 2000 A qualitative study

of childbirth as spoken about in midwives’ ante- and

postnatal consultations. Midwifery 16: 123–134

Pairman S 1998 The midwifery partnership: an explora-

tion of the midwife/women relationship. Masters of

Arts thesis University of Wellington, New Zealand

Patton M 1990 Qualitative evaluation and research

methods 2nd edn. Sage, Newbury Park

Sandelowski M 1986 The problem of rigor in qualitative

research. Advances in Nursing Science 8: 27–37

Stern C, Permezel M, Petterson C et al. 1992 The Royal

Women’s Hospital Family Birth Centre: the first 10

years reviewed. The Australian and New Zealand

Journal of Obstetrics and Gynaecology 32:

291–295

Strauss A, Corbin J 1998 Basics of qualitative research:

techniques and procedures for developing grounded

theory. Sage Publications, London

Wagner M 1994 Pursuing the birth machine: the appro-

priate search for birth technology. ACE Graphics,

Sydney

Normality and collaboration 193

Waldenstrom U 1998 Continuity of carer and satisfaction.

Midwifery 14: 207–213

Waldenstrom U, Lawson J 1998 Birth Centre Practices in

Australia. Australian & New Zealand Journal of

Obstetrics and Gynaecology 38: 42–50

Waldenstrom U, Nilsson C 1994 Experience of childbirth

in birth centre care: A randomised controlled study.

Acta Obstetricia et Gynecologica Scandinavica 73:

547–554

Waldenstrom U, Nilsson C, Winbladh, B 1997 The

Stockholm birth centre trial: maternal and infant

outcomes. British Journal of Obstetrics and Gynae-

cology 104: 410–418

Waldenstrom U, Turnbull D 1998 A systematic review

comparing continuity of midwifery care with standard

maternity services. British Journal of Obstetrics and

Gynaecology 105: 1160–1170

Walker JM, Hall S, Thomas M 1995 The experience of

labour: a perspective from those receiving care in a

midwife-led unit. Midwifery 11: 120–129

Whelan A 1994 Centering Birth: a prospective

cohort study of birth centres and labour wards.

PhD thesis. Department of Public Health, University

of Sydney.

Wood J 1997 An evaluation of the Family Birth Centre at

King Edward Memorial Hospital. Proceedings of the

Australian College of Midwives Tenth Biennial

National Conference, Sydney