Volume 4, Number 2, 2014

ISSN 2156-5287

International
Journal of
Childbirth
Official Publication of the International Confederation of Midwives

www.springerpub.com/ijc
 International Journal of Childbirth
Editors-in-Chief
Denis Walsh, PhD, RM Kerri D. Schuiling, PhD, CNM, NP, FACNM, FAAN
Division of Midwifery School of Nursing
University of Nottingham Oakland University
United Kingdom United States

Deputy Editor
Soo Downe, RM, MSc, PhD
School of Health
University of Central Lancashire
United Kingdom

Associate Editors
Maria Helena Bastose, MD, MSc, PhD Judith T. Fullerton, PhD, CNM, FACNM Jayne Marshall, PhD, MA, PGCEA, ADM,
Marie Berg, PhD, MNSc, MPH, RN, RM Vivette Glover, MA, PhD, DSc RM, RGN
Susan Bewley, MA, MD, FRCOG Mechthild Gross, RM, RN, MSc Etsuko Matsuoko, PhD
Terese Bondas, PhD, LicNsc, MNsc, RN, PHN Gill Gyte, MPhil Robyn Maude, PhD, MA (Midwifery), BN, RM, RN
Sheena Byrom, RM, MA Eileen Hutton, RM, RN, PhD Chris McCourt, PhD
Ngai Fen Cheung, PhD, MSc, RM, RGN Ken Johnson, PhD Marianne Mead, RM, PhD
Hannah Dahlan, RN, RM, BN(Hons), Holly Powell Kennedy, PhD, CNM, FACNM, Judith Mercer, BSN, MS, DNS
MCommN, PhD, FACM FAAN Mary Newburn, MSc
Frances Day-Stirk Patrick Lavery, MD Kerreen Reiger, MA, PhD
Marcos Dias, MD, PhD Nicky Leap, DMid, MSc, RM Verena Schmidt, RM
Grace Edwards, RN, RM, ADM, Cert Ed, M.Ed, PhD Heloisa Lessa, MS Julia Seng, PhD, CNM, FAAN
Jenny Gamble, RM, MHlth, PhD Amali Lokugamage, MBChB, BSc, MSc, MD, Theresa Ann Sipe, CNM, MPH, MN, PhD
Atf Gherissi, CM, MSc, PhD FRCOG Nick Taub, PhD
Ank de Jonge, PhD Lisa Kane Low, PhD, RN, CNM, FACNM Jim Thornton, MD, FRCOG
Eugene Declercq, PhD Ans Luyben, RM, PGDE, PDM, PhD Kerstin Uvnas-Moberg, MD, PhD
Raymond De Vries, PhD Margaret Maimbolwa, PhD Saras Vedam, RN, MSN, SciD(hc)
Declan Devane, PhD, MSc, PgDip(Stats), Rosemary Mander, MSc, PhD, RGN, SCM, MTD Kim Watts, PhD, PGCAP, MSc, RM, RN
DipHE, RGN, RM, RNT
International Confederation of Midwives
Frances Ganges
Chief Executive
The Netherlands
Board Members
Frances Day-Stirk Laurence Monteiro Mirian Teresa Solís Rojas
President Benin Perú
United Kingdom Mary Higgins Sue Bree
Debrah Lewis Ireland New Zealand
Vice-President Maria Papadopoulou Mary Kirk
Trinidad, West Indies Cyprus Australia
Marian van Huis Ingela Wiklund Věra Vránová
Treasurer Sweden Czech Republic
The Netherlands
Irene de la Torre
Deliwe Nyathikazi USA
South Africa

International Journal of Childbirth is published quarterly by Springer Publishing Company, LLC, New York.
Business Office: All business correspondence, including subscriptions, renewals, and address changes, should be addressed to Springer Publishing Company,
LLC, 11 West 42nd Street, 15th Fl., New York, NY 10036. www.springerpub.com
Editorial Office: Manuscripts for publication should be submitted electronically using Editorial Manager: www.editorialmanager.com/ijcbirth
Subscription Rates (per Year): For institutions: Print & Online, $292. For individuals: Print & Online, $53. Outside the United States—for institutions: Print
& Online, $371. For individuals: Print & Online, $95.
Permission is granted by the copyright owner for libraries and others registered with the Copyright Clearance Center (CCC) to photocopy any article herein
for $5.00 per copy of the article. Payments should be sent directly to: Copyright Clearance Center, 27 Congress Street, Salem, MA 01970. This permission
holds for copying done for personal or internal reference use only; it does not extend to other kinds of copying, such as copying for general distribution,
advertising or promotional purposes, creating new collective works, or for resale. Requests for permissions or further information should be addressed to
Springer Publishing Company, LLC.
Postmaster: Send address changes to International Journal of Childbirth/Springer Publishing Company, LLC,
11 West 42nd Street, New York, NY 10036.
Copyright © 2014 Springer Publishing Company, LLC, New York. ISSN 2156-5287
International Journal of Childbirth
Volume 4, Number 2, 2014

Editorial
Managing Risk or Facilitating Safety? 66
Hannah Dahlen

Articles
A Situational Analysis of the Status of Midwifery in North Africa
and the Middle East 69
Atf Ghérissi and Judith Marie Brown
Safe Arrivals: Responding to the Local Context in a Training Program for
Birth Attendants in Cambodia 77
Lois V. McKellar and Kevin Taylor
Immigrant New Mothers in Finnish Maternity Care:
An Ethnographic Study of Caring 86
Anita Wikberg, Katie Eriksson, and Terese Bondas
Experiences of Women Planning a Home Birth Who Require
Intrapartum Transfer to Hospital: A Metasynthesis of the
Qualitative Literature 103
Deborah Fox, Athena Sheehan, and Caroline Homer
Maternal Obesity and the First Birth:
A Case for Targeted Contemporary Maternity Care 120
Valerie J. Slavin, Jennifer Fenwick, and Jenny Gamble

News
Midwives: Changing the World One Family at a Time 130
Midwifery Development in China 130
Second Middle East and North Africa Regional Midwifery Conference,
Midwifery Education: Challenges and Opportunities 131
ICM Prague 2014: Midwives Improving Women’s Health Globally 132
EDITORIAL
Managing Risk or Facilitating Safety?
“Any intelligent fool can make things bigger,
more complex, and more violent. It takes a touch
of genius, and a lot of courage, to move in the
­opposite direction.”
—Albert Einstein
In 2012, conservationists, fishers, and community mem-
bers united across Australia to protect marine life from
the threat of super trawlers. This action led to banning
the giant boats from our waters. Super trawlers, measur-
ing up to 144 meters long, use nets up to 600 meters long
and can catch up to 250 tons of fish a day. The problem
with this method of fishing is it is indiscriminate and
the “bycatch” (unintended capture of other marine life)
includes endangered turtles, giant rays, and dolphins
(Greenpeace, 2014). Those who manage super trawlers
cannot of course see what is wrong with this approach
because they efficiently process the largest catches of
fish in the world. Tasmanian Tapp (2014) wrote a beau-
tiful song to protest the introduction of super trawlers
into Australian waters and asked poignantly, “How will
we explain to them (future generations) the damage we
have done?” (Tapp, 2014).
You may be wondering why I am writing about
super trawlers in the International Journal of Child-
birth (IJC). The questions I am asking in this editorial
are, has modern maternity care morphed into a super
trawler of risk, scooping up with its well-meaning “net”
the bycatch (healthy, young, childbearing women). I
will argue that our increasing focus on managing risk
is not the same as facilitating safety, and it is time for a
safety approach to replace the current risk management
approach.
Modern maternity care is not immune to the risk-
averse paradigm pervading the world. However, when
we become risk-averse, we invite other risks that we are
INTERNATIONAL JOURNAL OF CHILDBIRTH Volume 4, Issue 2, 2014
© 2014 Springer Publishing Company, LLC www.springerpub.com
66
often blind to. This is described as “earnestly filtering
the bath water whilst the baby is left to drown” (Ballat
& Campling, 2011). The giant super trawlers of mater-
nity care throw their ever-widening risk assessment,
risk screening, and risk avoidance nets out, pulling
more and more women into them along with the inevi-
table bycatch. When only 15% of low-risk primiparous
women give birth without medical intervention in
some of our models of care, then we have to admit we
have a problem (Dahlen et al., 2012). We know this is
less about women and more about our care; as in other
models with a strong social focus, these same low-risk
women have normal birth rates of more than 85%—the
complete opposite (Birthplace in England Collaborative
Group, 2011).
The risk management approach seeks to obviate
measurable risk and ignores the impact of perceived
risk and risk that is difficult to measure. Under this
paradigm, psychological, social, cultural, and spiri-
tual factors that may enhance safety, and are what
make us human, are hard to quantify and so are
ignored. It is hardly surprising then that ignoring
these important aspects of safety is leading increas-
ingly to traumatized women and dehumanized care,
and this creates other risks (Jackson, Dahlen, &
Schmied, 2012).
Under the risk management paradigm, if you
can’t count it, then it appears not to count and every
risk can be reduced or eliminated. In Australia, for
example, a young aboriginal woman flown out of her
remote community at 36 weeks of pregnancy to wait
for birth in a big city boarding house away from fam-
ily and friends, unable to birth “on country,” which
she believes connects the spirit of the child to the land,
may seem like a good way to manage the physical
risk associated with remote birthing (physical). Is this
approach, however, facilitating safety—emotional, spiri-
tual, cultural (Dietsch et al., 2011), and are there better
http://dx.doi.org/10.1891/2156-5287.4.2.66

ways to approach the issue (Van Wagner, Osepchook,
Harney, Crosbie, & Tulugak, 2012)? The risk manage-
ment approach has redefined birth from being a social
experience to a medical one that needs to be quantified
and managed (Hacking, 1990). Deviations from normal
are labeled outliers (e.g., women with longer labors),
and normality is progressively redefined until complex-
ity becomes the new normal.
Transferring women during planned homebirths
has bought our institutions into sharp relief for me. Fox,
Sheehan, and Homer (2014) publish a metasynthesis of
the experience of homebirth transfer in this edition of
IJC. Navigating locked doors, intercoms, birth rooms
designed for surgery not birth; passing the beautifully
framed hospital mission statements; espousing women-
centered care and promises of respect, dignity, and
evidence-based care, I am struck by how these contrast
with the inevitable fight to get a mat and a beanbag so
the woman does not have to be on the bed, the reaction
to requests for delayed cord clamping, the struggle to
scrounge up some form of acceptable sustenance from
sparse hospital kitchens, and the battle to use the pris-
tine clean bath for pain relief. I am struck by the fact that
our institutions are geared toward managing risk and
not about facilitating normality, and healthy women are
the bycatch of this all-pervading risk approach.
Managing risk is not the same as facilitating safety,
and it is time we woke up to this fact. If we banned the
word risk and embraced the word safety, could we trans-
form maternity care?
Odent (2014) describes the emergence of water
immersion after the historic student revolt in France
where an “audacious creativity” resulted, and the watch-
word was “it is forbidden to forbid.” He describes taking
advantage of this “transient cultural folly to do what
would have been impossible ten years before or ten
years after,” introducing water to help replace drugs in
labor (Odent, 2014). Perhaps it is time for a revolution
in maternity care (a bloodless one I hope) that unites
us to move the super trawlers of risk off our maternity
service shores. We could all do with some audacious
creativity in our large, highly streamlined, and over-
regulated maternity care environments. Continuity of
midwifery care is one very effective way to facilitate
safety through relationship-based care (Sandall, Soltani,
Gates, ­Shennan, & Devane, 2013) and could be argued
to not only be audaciously creative but also vulnerable
in our complex, procedural-driven organizations. If
we unite, disparate as we may be, with a common aim
to facilitate safety in maternity care, we may be able
Editorial  67
to stop the ­current bycatch resulting from the super
trawlers of risk. If we focused on safety and not risk,
on relationship-based care, not system-based care, we
could make maternity care safer for everyone (women,
health professionals, and organizations).
I want to end with Tapp’s (2014) words from his
song about super trawlers and encourage the same pas-
sion and unity in our profession—“Hold on tight! Get
ready to fight.”
Hannah Dahlen
Associate Editor
Professor of Midwifery, University of
Western Sydney, Australia
REFERENCES
Ballat, J., & Campling, P. (2011). Intelligent kindness. Glasgow,
United Kingdom: Bell & Bain.
Birthplace in England Collaborative Group. (2011). Peri-
natal and maternal outcomes by planned place of
birth for healthy women with low risk pregnancies:
The Birthplace in England national prospective cohort
study. British Medical Journal, 343, d7400. http://dx.doi
.org/10.1136/bmj.d7400
Dahlen, H. G., Tracy, S., Tracy, M., Bisits, A., Brown, C., &
Thornton, C. (2012). Rates of obstetric intervention
among low-risk women giving birth in private and pub-
lic hospitals in NSW: A population-based descriptive
study. British Medical Journal Open, 2, e001723. http://
dx.doi.org/10.1136/bmjopen-2012-001723
Dietsch, E., Martin, T., Shackleton, P., Davies, C., McLeod, M.,
& Alstond, M. (2011). Australian Aboriginal kinship:
A means to enhance maternal well-being. Women and
Birth, 24(2), 58–64.
Fox, D., Sheehan, A., & Homer, C. (2014). Experiences of
women planning a home birth who require intrapartum
transfer to hospital: A metasynthesis of the qualitative
literature. International Journal of Childbirth, 4(2),
103–119.
Greenpeace. (2014). 10 frightening facts about super trawlers.
Retrieved from http://www.greenpeace.org/australia/
en/news/oceans/top-10-facts-about-super-trawlers/
Hacking, I. (1990). The taming of chance. Cambridge, United
Kingdom: Cambridge University Press.
Jackson, M., Dahlen, H., & Schmied, V. (2012). Birthing out-
side the system: Perspectives of risk amongst Australian
women who have high risk homebirths. Midwifery,
28(5), 561–567.
68 Editorial
Odent, M. (2014). Water birth and sexuality. Glasgow, United
Kingdom: Clairview Books.
Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D.
(2013). Midwife-led continuity models versus other
models of care for childbearing women. Cochrane
Database of Systematic Reviews, (8), CD004667. http://
dx.doi.org/10.1002/14651858.CD004667.pub3
Tapp, C. (2014). Father to son. Retrieved from http://www.
youtube.com/watch?v=xoJxGPdK-PU
Van Wagner, V., Osepchook, C., Harney, E., Crosbie, C., &
Tulugak, M. (2012). Remote midwifery in Nunavik,
Québec, Canada: Outcomes of perinatal care for the
Inuulitsivik health centre, 2000–2007. Birth, 39(3),
230–237.
 ARTICLES

A Situational Analysis of the Status of Midwifery

in North Africa and the Middle East
Atf Ghérissi and Judith Marie Brown

Midwives from the Middle East and North African (MENA) region convened in Dubai, United Arab
Emirates in 2012 to engage for the first time ever in a discussion concerning regional strategic inter-
ventions to strengthen midwifery and the work of midwives in the Arab countries. The workshop was
an opportunity to establish a culture of positive and balanced collaboration and mutual understand-
ing among midwives and between midwives and other maternity care professionals including nurses
and obstetricians. Key challenges and opportunities in midwifery in the MENA region were identified.
­Participants agreed on strategic goals to strengthening midwifery education, regulation, and associa-
tions in the MENA region.
Keywords:  midwifery; MENA; education; regulation; association

INTRODUCTION AND BACKGROUND
The State of the World’s Midwifery Report (United
Nations Population Fund [UNFPA], 2011), the Millen-
nium Development Goals (MDGs): 2012 Progress Chart
(United Nations, 2012), and the Countdown to 2015
(World Health Organization [WHO], United Nations
Children’s Fund, 2012) documents offer evidence of
the international acknowledgment that progress toward
achievement of MDG5 (improve maternal health) has
been slow in most countries. Global action has been
accelerated to improve reproductive health and to reduce
both maternal and child mortality (MDG4). The “Global
Strategy for Women’s and Children’s Health” (Partner-
ship for Maternal, Newborn and Child Health, 2010)
has underpinned these efforts in several countries in
the Middle East and North African (MENA) region,
such as notably Djibouti, Morocco, Somalia, Sudan, and
Yemen. Many of the countries in the MENA region have
included midwives among their health human resource
personnel, but even where midwifery services exist, the
midwives face many issues and challenges related to
education, regulation, lack of distinct professional asso-
ciations, leadership development, and support.
The 22 Arab states can be divided into three
groups based on the percentage of deliveries attended
by skilled health personnel and the maternal mortality
ratio (Table 1). The first group, where both indicators
are balanced, contains small, mostly rich Gulf countries
as well as middle-income countries such as Lebanon. In
the second group, maternal mortality is between 50 and
100 deaths for 10,000 live births when the percentage
of assisted deliveries is at least at 80%, and this suggests
geographic, social, cultural, and economic barriers,
including the weak quality of maternal health services,
as in Djibouti for example. The third group has coun-
tries where the percentage of births attended by skilled
health personnel is at an average of 48% and the mater-
nal mortality ratio range is more than 100 and reaches
1,000, as in Somalia. In addition to other factors, the
situation in most countries in this group can be linked
to the lack of availability, accessibility, and affordability
of maternal services in remote and rural areas (Ghérissi,
2012; Ghérissi, Brown, & Eladawy, 2011).
Regardless of the indicators, midwives face similar
challenges such as low status of women, gender issues,
and workplace domination. In many of these countries,
childbearing women and their midwives are currently
experiencing unimaginable stress and hardships because
of the turmoil and trauma of revolution and war.
The impetus for the conduct of a situational analy-
sis of midwifery in the MENA region was the realization

INTERNATIONAL JOURNAL OF CHILDBIRTH Volume 4, Issue 2, 2014

© 2014 Springer Publishing Company, LLC www.springerpub.com
http://dx.doi.org/10.1891/2156-5287.4.2.69 69
70  Status of Midwifery in North Africa and the Middle East  Ghérissi and Brown

TABLE 1  Maternal Mortality Ratio and Deliveries Attended by Skilled Personnel in the Arab States
MDG5 (2010)

MATERNAL NEONATAL
DELIVERIES ATTENDED MORTALITY RATIO MORTALITY RATE
BY SKILLED HEALTH (DEATHS/100,000 LIVE (PER 1,000 LIVE BIRTHS)
COUNTRIES PERSONNEL BIRTHS) 2008–2012

Group of countries Qatar 100% 7 4

where the proportion of United Arab Emirates 100% 12 4
deliveries attended by Kuwait 99% 14 5
skilled health personnel Bahrain 97% 20 4
is high and the maternal Saudi Arabia 100% 24 5
mortality ratio is low Oman Sultanate 99% 32 5
Lebanon 97% 25 5
Group of countries Tunisia 95% 56 10
where the proportion Libya 100% 58 10
of deliveries by skilled Jordan 99% 63 12
­personnel and the Iraq 80% 63 20
­maternal mortality ratio Palestine — 64 13 (West Bank and Gaza)
are both high Egypt 79% 66 7
Syria 96% 70 9
Algeria 95% 97 17
Group of countries Morocco 74% 100 19
where the proportion Yemen 36% 200 32
of deliveries by skilled Djibouti 78% 200 33
personnel is low and the Comoros 62% 400 32
maternal mortality ratio Mauritania 57% 510 40
is high Sudan 23% 730 31
Somalia 9% 1,000 50
MENA region 95.9% 179 16.68

Note. Adapted from United Nations Population Fund. (2012). By choice not by chance: Family planning, human rights and development. State of the world
population. Retrieved from http://iran.unfpa.org/images/photo/EN-SWP2012_Report.pdf; and World Bank. (2012). Mortality rate, neonatal (per 1,000 live
births). Retrieved from http://data.worldbank.org/indicator/SH.DYN.NMRT

by the authors and others (midwives and donors) that
the “collective force” of midwives and their respective
and supportive delegations from Arab states could be
unleashed to develop a sustainable and dynamic regional
strategic plan for the strengthening of midwives and
midwifery services. This article presents the process and
outcome of that strategic planning meeting.
MATERIAL AND METHODS
The situation analysis was conducted as a qualitative
assessment and not as a formal research project. Accord-
ingly, although formal human subjects’ approval was not
required, the assessment was nevertheless conducted, in
accord with all principles of ethical conduct of research
that respected total anonymity of respondents.
The specific objective of the analysis was to conduct
a situational analysis on current midwifery education,
regulation, and association service provision within coun-
tries in the MENA region. The delineation of regional
strategic goals and interventions used a consensus model
and evolved through a progressive process that involved
participants in identifying and discussing current gaps
and challenges according to their own respective expe-
rience, in agreeing to priority issues to be addressed
and then, in translating them into strategic goals and
interventions.
Sample
There were 39 delegates from the MENA midwifery
region, representing 10 countries (Djibouti, Iraq, Morocco,
Oman, Palestine, Qatar, Somaliland, Sudan, United Arab
Emirates [UAE], and Yemen), who were gathered in Dubai
for that purpose. Participants included midwife educators,
midwife regulators, representatives of midwives and nurs-
ing associations, representatives of ministries of health,
 Status of Midwifery in North Africa and the Middle East  Ghérissi and Brown  71
and student midwives. The International Confederation
of Midwives (ICM) provided technical support, and the
WHO participated through personal presence and finan-
cial support of 3 delegates.
Procedures
The workshop process consisted of plenary sessions as
well as subregional common language working group
sessions where participants introduced their respective
situations, raised common issues and challenges, and
identified ways to resolve them. Groups were asked to
report on major strengths, challenges, and opportuni-
ties and to make key strategic suggestions for the way
forward.
Data Analysis
The comments and suggestions have been treated
using the directed content analysis approach (Hsieh &
­Shannon, 2005; Mayer & Deslauriers, 2000).
RESULTS
The findings of the situation analysis highlighted key
characteristics of midwifery in the countries of the
MENA region that illustrate not only the major strengths
and challenges faced but also the awareness of existing
opportunities that enable midwifery in the region to
move forward.
Landscape of Midwifery in the MENA Region
It appears obvious that in the MENA region, the funda-
mental issue faced by midwives is their unclear identity
buried among a multitude of cadres trained, employed,
and empowered as midwives despite the lack of quali-
fications according to the “ICM International Defini-
tion of the Midwife” (ICM, 2011). Several categories of
health workers are identified as midwives in the region,
including registered midwives, enrolled midwives, com-
munity midwives, clinical officers, community health
nurses, community health extension workers, and often,
traditional birth attendants. This situation is worsened
by donor demands for training programs for even more
new cadres to provide midwifery services. In most of the
countries, midwives do not have a formal specific job
description. That makes their definition even weaker
and does not allow a distinction between the roles of
midwives and nurses.
The medical rather than a midwifery model of
care, the doctors’ domination partly because of the
emerging private sector, the medicalization of the pro-
fession, and the frustrated feeling of a subordinate rela-
tionship toward the doctor and/or the nurse are other
challenges faced by the midwives in the region, who suf-
fer from being led by other professions. The midwives
are often perceived as serving in the role of obstetric
assistant. As a consequence, midwives are characterized
by a lack of self-confidence, a lack of autonomy, and
low status.
Additional challenges to role progression include
the absence of both career planning and promotional
prospects and by poor conditions of service (salaries,
educational benefits). The work of the midwife carries
stigma in some countries. Midwives are often exposed
to burnout through working in a precarious and at times
unsafe working environment, where service quality is
often poor, not based on evidence and compounded
by the lack of support services such as a sound referral
system.
In some countries, war and political unrest have
led to the destruction of infrastructure and instability.
Midwives are geographically isolated in several practice
settings, given the size of the country.
There is often little community support for mid-
wifery services, justified by dissatisfaction with the
quality of midwifery services. All of this is demotivating
and demoralizing and contributes highly to midwives’
migration mostly to accept positions with high salaries
and privileges offered by some countries within and
outside the region.
The global advocacy targeting the MDGs 4 and
5 created a global awareness of midwifery services fol-
lowed by global mandates and advocacy on behalf of the
profession. The ICM has gained recognition as a refer-
ent and credible international professional organization
not only among midwives but also among other profes-
sional organizations such as International Federation
of Gynecology and Obstetrics and donor agencies. The
tools developed by ICM are considered a standardized
framework for midwifery education such as the educa-
tion, and regulation standards, the essential competen-
cies, and the definition of the midwife regularly updated
(ICM, 2011).
Such a historical global voice for world midwifery
inspired midwives in the MENA region to become orga-
nized and work toward autonomy in practice. It was also
perceived as an opportunity by midwives for more unity
72  Status of Midwifery in North Africa and the Middle East  Ghérissi and Brown
with decision makers in health, for advocacy including
professional collaboration and partnership, to broaden
the mandate of midwifery, and to agree and define the
scope of practice for midwives.
The existence of different and humanistic models
of care such as normal birth, safe childbirth, and conti-
nuity of care were identified as the preferred model of
care to replace the actual and very evident dominant
medical model that prevails. The continuum of care
model had already been adopted by midwives in some
countries, resulting in an expansion of the midwifery
scope of practice.
Participants recognized unanimously that mid-
wives are henceforth self-empowered and are deter-
mined to improve their image and their status. They
commented on the critical importance of increased
community awareness of the need for midwives by
women and their families in the quest for reinforcement
and validation of this empowerment.
Midwifery Education
Midwifery education in the region is challenged by lack
of resources often because of the absence of a specific
budget line. At the same time, education fees for mid-
wifery students are very high in some countries (e.g., Pal-
estine). For some countries, the education programs are
donor-dependent and the donors themselves have tended
in the past to sponsor “band-aid” solutions to problems
such as starting new cadres without much reflection.
In the countries of the MENA region, as in many
regions worldwide, midwifery education programs suf-
fer from a lack of sufficient qualified and experienced
teachers within the specialty of midwifery, from different
standards of teaching, from lack of adequate training in
clinical teaching, from poor preceptorship, and generally,
from a lack of a clear and standard profile of midwifery
teachers. Midwives and midwifery teachers have little
opportunities to access education and training according
to standards, or continuing assurance systems for quality
of teaching. They have low salaries and work with inad-
equate training resources (human and material), poor
administrative arrangements, and lack of flexibility in
decision making. Moreover, there is a general need for
education materials in the Arabic language.
In all countries, midwifery education programs
are led by doctors or by nurses but rarely by midwives.
The emergence of private midwifery schools and private
medical practice, where the same doctors are very often
leaders, managers, supervisors, teachers, and employers,
contribute to strengthen medical domination and con-
fuse and undermine midwifery education.
Those schools have courses that fall short of rec-
ognized standards, have been set up outside of public
government systems and universities, and, in fact, are
some owned and operated by medical doctors. Yemen
and Tunisia are among the countries very concerned by
this important issue.
Major strengths of midwifery education in many of
the countries include the fact that most public education
is free of cost and that countries have a common entry
level, which is secondary education. In some countries,
scholarships or incentives are provided to midwifery
students (such as transportation fees and opportunities
for learning experiences in countries located within the
region). Preceptorship has been newly introduced in the
learning approach in a few countries.
Incentives for teachers and graduates include the
elective experiences in other countries. A few countries,
such as the Oman Sultanate, have set very high qualifi-
cations for the teachers and have ensured a good supply
of resource and simulation materials.
Midwifery Regulation
Participants had very little to say about midwifery regula-
tion in the MENA region not least because of the absence
of regulatory systems, of relicensing procedures, and of
regulatory bodies or enforcement. In a few countries,
when they do exist, they are fragmented and very weak.
This lack of understanding by governments and
policy makers of the importance to public health and
safety of a regulatory framework for midwifery is evi-
denced by the inconsistent commitment and support to
midwifery regulation implementation within the region.
In the few countries in which some form of regula-
tion has been reported, the body has various titles and
may have responsibility for regulation of other cadres,
although they may all be identified and assigned as
midwives in the workplace. The international definition
of the midwife, as developed by ICM, is acknowledged
and followed in some countries, such as in Morocco, in
Oman, in the UAE, and more recently, in Iraq.
Midwifery Associations
There are midwives associations, nurse-midwives asso-
ciations, or even a midwifery committee in most of
 Status of Midwifery in North Africa and the Middle East  Ghérissi and Brown  73
the countries (Algeria, Djibouti, Iraq, Libya, Morocco,
Oman, Palestine, Somaliland, Sudan, Tunisia, and UAE).
All are legally recognized and all have a board, excluding
Palestine. Most of them have developed a vision and a
mission statement, except for Iraq and P ­ alestine. Most
are managed by employed staff and volunteers (Yemen,
UAE, and Somaliland), others only by volunteers (Pal-
estine, Djibouti). The associations are mainly financed
by member fees (Yemen, Djibouti), by member fees and
donors (Yemen, Somaliland), by member fees and fund
raising (UAE), by donors (Sudan), or by a nongovern-
mental association (NGO; Palestine).
All of the associations depend in part on the work
of volunteers and often work without sufficient material
or financial resources to manage administration and
secretarial demands. Membership fees from midwives
are a constant challenge because of low salaries and eco-
nomic conditions within countries.
Many associations report lack of cohesion
amongst midwives, lack of advocacy and social mar-
keting skills, and lack of confidence and autonomy,
which block initiatives. Partnership relations are very
limited, and the existing associations face difficulties in
recruitment, in finding legal support, and sometimes
in having too few midwives to form and maintain an
association. All these difficulties threat the sustain-
ability of those associations and weaken their visibility
and credibility.
Good links with other professional organizations
as well as a feeling of power have been reported by the
associations represented in the workshop. The exist-
ing professional associations, the new achievements
for some of them such as for Morocco and Iraq, and
the network and support provided to midwives on
the field in Gaza such as by the midwifery commit-
tee in Palestine offer the opportunity to form inter-
nal ­networks with other associations to expand and
exchange programs.
DISCUSSION
The workshop provided a forum of exchange and dis-
cussion to develop regional strategic interventions to
strengthen midwifery and the work of midwives in the
Arab countries and to establish a culture of a positive
and balanced collaboration and mutual understanding
between the midwives themselves and between mid-
wives and other maternity care professional including
nurses and obstetricians.
The commitment to a midwifery reform in the
region is strong because of current political will and
because of the obvious and visible global support
extended at country level from donor agencies such as
UNFPA, WHO, and the Spanish Agency for Interna-
tional Development Cooperation described as partners
at global, regional, and national levels.
At country level, there is a general willingness to
invest in midwives, and in some countries, the govern-
ment is beginning to recognize and support them within
the system and the community. The engagement of the
ministries of health is also a determinant of support to
any midwifery education reform.
The adoption of ICM-linked competency-based
curricula for midwifery education has provided
a better understanding of the concept of compe-
tence. The integration of midwifery programs of
study within degree-granting pathways, such as the
licence-master-and doctorate level has been per-
ceived in some countries as a reform that offers mid-
wives the opportunity of academic advancement and
career progression.
CONCLUSION
Based on the gaps highlighted and prioritized, work-
shop participants developed 14 regional strategic goals
and 34 strategic interventions to enhance and upscale
midwifery in the MENA region (Table 2). They also
generated the Dubai declaration (ICM, 2012) using
their collective voice to call on the governments, donors,
and fellow midwives to commit to strengthening and
­scaling up of the midwifery profession in their respec-
tive countries.
Midwives from the MENA region demonstrated
an awareness and determination to defend and place
value on their image and status. If such determination
can be recognized and supported by governments and
within the health systems and communities where they
work, there is every chance that midwives can and will
realize their vision and mission. The existing national
plans for maternal and newborn health services in
most of the countries are opportunities for midwives
to exploit.
The Dubai workshop was the beginning of a
strong commitment by midwives and others for a better
future for the profession, for the quality of midwifery
services, for a better health system, and by extension, for
a better woman’s health in the region.
74  Status of Midwifery in North Africa and the Middle East  Ghérissi and Brown
TABLE 2  Midwifery Regional Strategic Goals
REGIONAL STRATEGIC GOALS
Midwifery Regulation
1. To ensure countries of the MENA region
have in place a statutory body for mid-
wives to ensure safe midwifery practice
2. Well-established regulatory systems in
countries
3. Set/stand a midwives code of ethics for
MENA region
4. Accelerate the reviewed regulatory status
of midwives—Morocco.
Midwifery Professional Associations
1. Establishment of independent midwifery
associations within MENA countries based
on ICM definition of the midwife
2. Deploy resources from UNFPA and WHO.
3. Register country associations with the ICM.
4. Develop midwifery leaders to ensure
midwives are the lead professionals influ-
encing positive outcomes for women and
their families.
Midwifery Education
1. Rationalize midwifery education.
2. Enhance midwifery education and
­practice by developing an accreditation
system for education.
3. Prepare and improve midwifery faculties
based on the ICM standards and accord-
ing to country needs.
STRATEGIES
•  Develop the concept of supervision of midwifery practice through the govern-
ment and MOH and midwifery and nursing council pathways.
•  Establish legislation/policy to monitor accountability, role and responsibility,
midwives rules, and code of practice and ethics.
•  All midwives to maintain professional portfolio and demonstrate evidence of
continuing professional development
•  Establish quality assurance mechanisms that are transparent and include risk
management and reflective practice.
•  Scope of midwifery practice to be adapted from the ICM to ensure definition of
the midwife defines the role and responsibility of the midwife
•  Develop and get a midwifery act approved by parliament.
•  Advocate for independent and autonomous midwifery practice.
•  Strengthen and implement midwifery scope of practice and ethics code,
­licensing, and relicensing requirements and procedures.
•  Establish a special regional committee
–  to develop the deontological code for midwives
–  to review by stakeholders
–  for distribution
–  for monitoring and evaluation
•  Establish and strengthen midwifery professional associations to meet application
requirements.
•  Undertake fundraising for the association.
•  Lobby for membership of the association amongst midwives.
•  Availing human and financial resources for midwifery association
•  Use technical assistance from the ICM headquarters.
•  Identify potential MENA region leaders.
•  Develop regional leadership programs.
•  Develop regional partnership initiatives.
•  Encourage those in charge of midwifery education programmes to include
­professional and management skills development.
•  Organize a MENA forum to focus on midwifery leadership and management.
•  Undertake assessment of country needs.
•  Comparison of needs with existing cadres
•  Prioritization of needs and cadres
•  Gradual elimination of redundant cadres and focus on strengthening of skill and
competencies of the priority cadres
•  Establish committee for accreditation system from representatives from higher
education, MOH, and midwifery association with support from the ICM.
•  Advocacy for midwifery profession in the community
•  Develop an approved curriculum based on international standards.
•  Establish standards for accreditation.
•  Train committee members in accreditation system.
•  Enhance the number of midwifery teachers.
•  Homogenize the instruction of teachers.
 Status of Midwifery in North Africa and the Middle East  Ghérissi and Brown  75

TABLE 2  Midwifery Regional Strategic Goals (cont.)

REGIONAL STRATEGIC GOALS STRATEGIES

Midwifery Education
4. Attract more students to midwifery
education so as to retain midwives in the
profession.
5. Establish a bridging program to unify the
midwifery profile and achieve a better
quality of care.
6. Establish a functional regional resource
center for midwives.
•  Coach young midwives affected to the rural areas.
•  Establish and develop a bridging programme.
•  Undertake coordination between the policy and decision makers to develop
and implement the programme.
•  Undertake human resources planning for gradual transition.
•  Use the center for regional training, e-library, workshop and conferences, skills
building, and improvement of networking and strengthening of partnerships
through periodic conferences.

Note. MENA 5 Middle East and North Africa; MOH 5 ministry of health; ICM 5 International Confederation of Midwives; UNFPA 5 United Nations
Population Fund; WHO 5 World Health Organization.

REFERENCES United Nations. (2012). Millennium development goals: 2012

Ghérissi, A. (2012). Midwifery education in the Middle East and
North Africa: Challenges and opportunities. Retrieved
from http://www.whiteribbonalliance.org/index.cfm/
news-blogs/wra-blogs/midwifery-education-in-the-
middle-east-and-north-africa/
Ghérissi, A., Brown, J. M., & Eladawy, M. (2011). The state of the
world’s midwifery report: Midwifery in North Africa and
the Middle East background paper. Retrieved from http://
www.unfpa.org/sowmy/resources/docs/background_
papers/23_GherissiBrownElAdawy_Midwifer y
NorthAfricaMiddleEast.PDF
Hsieh, H., & Shannon, S. (2005). Three approaches to qualita-
tive content analysis. Qualitative Health Research, 15(9),
1277–1288.
International Confederation of Midwives. (2011). ICM inter-
national definition of the midwife. Retrieved from
http://www.internationalmidwives.org/assets/uploads/
documents/CoreDocuments/CD2011_001%20ENG
%20Definition%20of%20the%20Midwife.pdf
International Confederation of Midwives. (2012). Middle
East and North Africa (MENA) midwifery collaborative.
Retrieved from http://www.internationalmidwives.org/
news/?nid524
Mayer, R., & Deslauriers, C. (2000). Quelques éléments d’analyse
qualitative (Chapitre 7). In R. Mayer, F. Ouellet, M. C.
Saint-Jacques, & D. Turcotte (Eds.), Méthodes de recherche
en intervention sociale (p. 162). Quebec, Canada: Gaëtan
morin éditeur Itée.
Partnership for Maternal, Newborn and Child Health.
(2010). Global strategy for women’s and children’s health.
Retrieved from http://www.who.int/pmnch/topics/
maternal/201009_globalstrategy_wch/en/
progress chart. Retrieved from http://www.un.org/­
millenniumgoals/pdf/2012_Progress_E.pdf
United Nations Population Fund. (2011). The states of the
world’s midwifery report 2001. Retrieved from http://
www.unfpa.org/sowmy/resources/en/main.htm
United Nations Population Fund. (2012). By choice not by
chance: Family planning, human rights and develop-
ment. State of the world population. Retrieved from
http://iran.unfpa.org/images/photo/EN-SWP2012_
Report.pdf
World Bank. (2012). Mortality rate, neonatal (per 1,000 live
births). Retrieved from http://data.worldbank.org/indi-
cator/SH.DYN.NMRT
World Health Organization, United Nations Children’s Fund.
(2012). Progress towards Millennium Development
Goals 4 and 5. In Countdown to 2015: Maternal, new-
born, & child survival. Building a future for women and
children: The 2012 report. Retrieved from http://www.
countdown2015mnch.org/documents/2012Report
/2012-part-2.pdf
Acknowledgments. The authors would like to acknowledge
the following people: Dr. Judith Fullerton, independent
consultant, for editorial assistance; Ms. Jane Abdulali, chair
of the Midwifery Section of the UAE Nursing, Dr.  Grace
Edwards, vice chair of the Midwifery Section of the UAE
Nursing Association and assistant director of Nursing
­S ection, clinical programmes manager, Corniche Hospital,
Abu Dhabi, UAE, Dr. Jo Hubbard, education manager,
Corniche Hospital, Abu Dhabi, and Ms. Fatima Al Khatib,
senior nurse advisor, Ministry of Health, UAE, for valuable
technical support; Ms. Frances Day-Stirk, ICM president,
and Ms. Agneta Bridges, ICM past secretary general, for
financial assistance; and Dr. Maha Eladawy, senior regional
76  Status of Midwifery in North Africa and the Middle East  Ghérissi and Brown
reproductive health adviser, Arab States office of the
UNFPA, for financial assistance.
Correspondence regarding this article should be directed to
Atf Ghérissi, PhD, MSc, CM, High School for Sciences and
Health Techniques, Tunis El Manar University, Tunis 1006,
Tunisia. E-mail: atfgherissi@yahoo.fr
Atf Ghérissi, PhD, MSc, CM, assistant professor, Education
Science, High School for Sciences and Health Techniques,
Tunis-El Manar University, Tunis, Tunisia.
Judith Marie Brown, CM, consultant (midwifery), Adelaide,
South Australia (formerly director of Nursing and Midwifery
Development, Dubai, UAE).
Safe Arrivals: Responding to the Local Context
in a Training Program for Birth Attendants
in Cambodia
Lois V. McKellar and Kevin Taylor

The World Health Organization (WHO) recommends that every woman should have a skilled birth
attendant (SBA) attend her birth; however, until this ideal is met, traditional birth attendants (TBA)
continue to provide care to women, particularly in rural areas of countries such as Cambodia. The lack
of congruence between an ideal and reality has caused difficulty for policy makers and governments.
In 2007, The 2h Project, an Australian-based, nongovernment organization in partnership with a local
Cambodian organization, “Smile of World,” commenced the “Safe Arrivals” project, providing annual
training for SBAs and TBAs in the rural provinces of Cambodia. Following implementation of this
project, feedback was collected through a questionnaire undertaken by interviews with ­participants.
This was part of a quality assurance process to further develop training in line with WHO recommen-
dations and to consider the cultural context and respond to local knowledge. Over a 2-year period,
240 birth attendants were interviewed regarding their role and practice. Specifically, through the
responses to the questionnaires, several cultural practices were identified that have informed training
focus and resource development. More broadly, it was evident that TBAs remain a valuable resource for
women, acknowledging their social and cultural role in childbirth.
Keywords: midwifery; health promotion; maternal health; Millennium Development Goals

INTRODUCTION achieve universal access to reproductive health services

Each year across the world, more than 536,000 women
die because of complications developed during preg-
nancy and childbirth, and 10 million more suffer debili-
tating illnesses and lifelong disabilities. Pregnancy and
childbirth are the leading cause of death and disability
for women in developing countries (Kurjak & Bekavac,
2001; United Nations [UN], 2008). Despite substantial
commitment by world leaders, there has been minimal
progress in reducing maternal and infant mortality. The
UN (2008) Millennium Development Goal (MDG) 5
that aims to reduce maternal mortality by 75% and to
Because of the context of this study, ethical approval could
not be obtained through the usual route. However, because
of the need to publicize Cambodian birthing practices, the
editors decided to accept the article on this occasion.
by 2015 has made the least progress of all MDGs. At the
global level, maternal mortality decreased by 1% per
year between 1990 and 2005—far less than the 5.5%
annual improvement needed to reach the target (United
Nations, 2008, p. 25). At this rate, MDG 5 will not be
met in Asia until 2076 and years later in Africa (Ugal,
2010, p. 4).
In Cambodia, the maternal mortality ratio (MMR)
is officially 540 for every 100,000 live births (World
Health Organization [WHO], United Nations Children’s
Fund, 2010). The unofficial MMR is around 700 per
100,000. This means that a pregnant woman in Cam-
bodia has 83 more times the chance of dying than a
pregnant woman in Australia. The “official” maternal
death rate accounts for 18% of all deaths of Cambodian
women aged 15–49 years; the reality would be much
higher (WHO, United Nations Children’s Fund, 2010).
In rural and remote Cambodia, where 85% of the

INTERNATIONAL JOURNAL OF CHILDBIRTH Volume 4, Issue 2, 2014

© 2014 Springer Publishing Company, LLC www.springerpub.com
http://dx.doi.org/10.1891/2156-5287.4.2.77 77
78  Safe Arrivals  McKellar and Taylor
population live, only 28% of women have a skilled birth
attendant (SBA) present during delivery ­(Yanagisawa,
Oum, & Wakai, 2005). For most laboring women, the
most common birth assistant is a traditional birth
attendant (TBA). WHO provides a definition of the
TBA as “a person who assists the mother during child-
birth and who initially acquired her skills by delivering
babies herself or through apprenticeship to other TBAs”
(WHO, 1992). TBAs comprise a large proportion of
accoucheurs throughout the world (Kruske & Barclay,
2004). Certainly, in Cambodia, following the civil upris-
ing and subsequent devastation, TBAs have been the
predominant maternity care provider for most women,
with most of these women learning their trade from
other TBAs or by trial and error.
During the 1970s and 1980s, providing training
to TBAs was adapted as a strategy to reduce maternal
and neonatal mortality. Many countries engaged in
training programs with a focus on providing antenatal
care and managing intrapartum and postpartum emer-
gencies. Notably, many programs were implemented
based on a strong Western medical ideology (Kruske
& Barclay, 2004). During the 1990s, it became evident
that maternal mortality worldwide was not decreasing,
and in 1996, the WHO changed the focus from the need
to provide women with a trained attendant to a skilled
attendant. Most recently, according to the State of the
World’s Midwifery Report (United Nations Population
Fund, 2011), there has been a call for a focus on global
efforts to ensure all women have access to a qualified
midwife. However, until this ideal is met, TBAs con-
tinue to provide care to women, particularly in rural
and remote areas of countries such as Cambodia. In a
Cochrane review commentary regarding TBA training,
MacArthur (2009) states
Although a skilled birth attendant for all women
is obviously the ideal, in many developing
countries, even if such workers were acceptable,
there is insufficient availability and the poor
rural areas do not offer attractive employment
options. It may therefore be years before this is a
feasible option.
It has been suggested that the apparent lack of
success in training TBAs may be caused by the use
of maternal mortality (MM) as one of the key deter-
minants of success. Measuring MM is fraught with
difficulty in many developing countries because of
underreporting or the inability to use reliable tools to
collect data. Furthermore, it has been recognized that
many training programs have been based on a biomedi-
cal model, which is not responsive to cultural worldview
or local context (Kruske & Barclay, 2004). In a review of
the effect of shifting policies on TBA training, Kruske
and Barclay (2004, p. 309) acknowledged that “rarely
was local knowledge incorporated into education cur-
ricula” and that consultation with the training partici-
pants was limited. This article describes the findings of
a questionnaire that sought to consider the cultural con-
text and incorporate local knowledge into the develop-
ment of training for birth attendants in Cambodia. The
questionnaire was implemented through an Australian-
based nongovernment organization (NGO), The 2h
Project, working in partnership with the Cambodian
government, Ministry of Health, and provincial health
services to provide training through the Safe Arrivals
program to both traditional and skilled birth attendants
in rural provinces throughout Cambodia.
PROGRAM
The Safe Arrivals training program provides 3-day
intensive residential workshops for TBAs and SBAs.
A voluntary team of six to eight Australian midwives,
including academic staff from tertiary institutions,
provides interactive teaching sessions and practical
demonstrations through a team of official Cambodian
interpreters. The program covers a range of basic skills
and evidence-based practices across topics such as con-
traception, sexually transmitted infections, nutrition,
infection control, breastfeeding, immunization, as well
as care during pregnancy and childbirth. In consultation
with the Ministry of Health, all TBAs and SBAs in the
province where workshops are conducted are required
to attend, and in return, transportation, accommoda-
tion, meals, and wages are provided by The 2h Project.
To provide an understanding of the local con-
text and embed a quality assurance process to inform
further development of the program, a questionnaire
was designed to gather information and describe the
current practice of the birth attendants participating in
this program. Both the Safe Arrivals training program
and a proposal for the questionnaire were submitted to
the Cambodian Ministry of Health. A memorandum of
understanding (MOU) was provided for the training to
be conducted in a specified number of provinces, and
approval was given for the questionnaire to be under-
taken concurrently. Working as “outsiders” in develop-
ing countries can be fraught with numerous challenges,
 Safe Arrivals  McKellar and Taylor  79

How much training have you had?

Why did you become a birth attendant?
Do you visit the mother before she has a baby? If yes, how many times?
Have you heard of mothers getting sick after the birth of their baby?
What would you do if they got sick?
Have you heard of mothers dying from this sickness?
Have you heard of babies getting sick in the first few weeks after being born?
What would you do to help these babies?
Have you heard of babies dying from this sickness?
What traditions/customs do mothers follow before and after the baby is born?

FIGURE 1  Example of questions used in the interview.

particularly when trying to follow strict ethical guide-
lines and processes. At the time of this project, only a
small number of NGOs were being given approval to
deliver birth attendant training, and being granted an
MOU was seen as highly commended and was respect-
fully accepted.
Over a period of 2 years, 240 out of a possible 897
Cambodian birth attendants participating in the Safe
Arrivals training program completed the questionnaire
while attending the workshop. Because of a lack of writ-
ten literacy, the questionnaire was conducted through
face-to-face interviews. Attendants at the training were
invited by the interpreters to participate in the interview.
Women were provided verbal information about the
questionnaire, and verbal consent was obtained; how-
ever, all data collected were documented anonymously.
The questionnaire was purposely designed to provide
birth attendants with an opportunity to describe their
experiences. The questionnaire collected demographic
and descriptive data through a range of closed- and
open-ended questions. Examples of the questions are
included in Figure 1. The questionnaire was initially
developed in English and subsequently translated to
Khmer to ensure that the questions would be appro-
priately understood by the Cambodian women. The
interview was conducted by the midwives providing the
training when they were not engaged in teaching. An
interpreter was used to facilitate the interview between
the midwife and the birth attendant and was provided
a copy of the written questionnaire in both English and
Khmer. Responses from the women to the questions
were provided through the interpreter and documented
in English by the midwife at the time of the interview.
Interviews were not recorded because this may have
been inhibited honest conversations. At times through-
out the interview, the birth attendants were reluctant to
answer some questions, and the interpreters explained
that this was because of a fear of being held responsible.
The birth attendants came from across four different
provinces, Kampong Speu, Ta Keo, Pursat, and Prey
Veng. Table 1 provides demographic data to describe
each province.

TABLE 1 Demographic Data Regarding Provinces Included in Training

PROVINCE
Kampong Speu Prey Veng Ta Keo Pursat

Total population 574,597 978,659 811,732 355,592

No. of health centers 50 90 70 30
No. of midwives 2–4 2–4 2–4 2–4
No. of TBAs 90% 90% 90% 90%
Maternal deaths per year 17–20 17–20 12–15 14–18
Targeted districts Chbar Mon, Samrong Kam Chay Mear, Prey Don Keo, Bati, Prey Sampov Meas, Ba Kan,
Tong, Phnom Sruoch, Veng, Masang Kabass Kra Kor, Kan Dieng,
Oudong Phnopm Kra Vanh,
Veal Veang

Total trainees 193 204 250 250

Note. TBAs 5 traditional birth attendants.

80  Safe Arrivals  McKellar and Taylor

Data from the questionnaires were collated.
Demographic data, and data regarding work practices of
the TBA, such as number of antenatal visits conducted,
were analyzed as simple statistics. Qualitative data from
the interviews were analyzed for commonly occurring
ideas and issues that appeared to be of particular sig-
nificance. The purpose of this analysis was to inform
the further development of the Safe Arrivals training
program by providing insight into the experiences of the
participating birth attendants.
FINDINGS
Out of the 240 birth attendants, 82 (34%) considered
themselves SBAs, whereas 156 (65%) identified them-
selves as TBAs, and 2 (1%) women did not classify
themselves. The age of the birth attendants varied, with
the TBA being older on average than the SBA. The aver-
age age range for the SBA was between 35 and 54 years;
the average age range for the TBA was between 45 and
64 years (Table 2). Regarding training, 40 (49%) SBAs
had 12 months training, whereas 23 (28%) had less than
12 months; for TBAs, 94 (60 %) TBAs had 3 days train-
ing or less, and half of these had no training (Table 2).
Interestingly, 67 (43%) TBAs had practiced for greater
than 30 years with only 7 (11%) having practiced for 9
years or less. This contrasted with 40 (49%) SBAs having
practiced for less than 20 years (Table 2). This is con-
sistent with the WHO change of emphasis during the
1990s to provide SBAs for women during birth.
Birth attendants were asked about the provision
of antenatal care. There were 78 (95%) SBAs and 124
(80%) TBAs who visited the mothers during the ante-

TABLE 2 Demographic Data Regarding Birth ­Attendants

SBA TBA

Age range in years (n 5 82) % (n 5 156) %

,25 years 4 4.9 0 0.0

25–34 years 7 8.5 3 1.9
35–44 years 30 36.6 10 6.4
45–54 years 29 35.4 59 37.8
55–64 years 8 9.8 51 32.7
.65 years 2 2.4 33 21.2
N/A 2 2.4 0 0.0

Length of training

None 0 0.0 33 21.2

1–3 days 9 11.0 61 39.1
,3 months 3 3.7 27 17.3
3–6 months 11 13.4 6 3.8
12 months 40 48.8 10 6.4
18 months 2 2.4 0 0.0
24 months 3 3.7 2 1.3
.24 months 12 14.6 2 1.3
N/A 2 2.4 15 9.6

Length of practice

,5 years 7 8.5 6 3.8

5–9 years 3 3.7 5 3.2
10–14 years 13 15.9 13 18.3
15–19 years 17 20.7 9 5.8
20–24 years 11 13.4 19 12.2
25–29 years 10 12.2 29 18.6
.30 years 5 6.1 67 43.0
N/A 16 19.5 8 5.1

Note. SBA 5 skilled birth attendant; TBA 5 traditional birth attendant.


natal period. There were 61 (74%) SBAs who visited
the women at least three times, with 27 (33%) visiting
the women more than five times. There were 78 (50%)
TBAs who visited the women at least three times, with
only 16 (10%) visiting more than this during the ante-
natal period. They were asked to describe what they
did during the visits. Predominantly, the TBA would
feel the mother’s abdomen to determine the position of
the baby and in particular, the baby’s head. They would
also check that the baby was moving. Some of the TBAs
indicated that they gave the women advice. The SBA
also checked the women’s abdomen identifying that
they would check the fundal height and position. They
would also listen to the fetal heart rate and take a blood
pressure reading.
During the interview, the midwife tried to gain
an understanding regarding the type of problems that
the birth attendants might encounter and how they had
managed these. Initially, this question was met with a
guarded response, and there was limited information
provided. It was suggested by the interpreter that the
birth attendants were reluctant to discuss problems or
poor outcomes because they were fearful they would be
held responsible. The question was reworded to ask if
they had heard of any problems other birth attendants
faced during pregnancy, birth, and following birth
and what was done to manage these problems. The
most common problems identified by both SBAs and
TBAs were bleeding, high blood pressure, swelling and
seizures, headaches, fever, long labor with obstruc-
tion, and retained placenta. Regarding the baby, the
birth attendants described stillbirth or babies born
unconscious because of long labors, babies born blue,
­breathing difficulties, weakness, fever, cough, yellow
babies, and seizures.
Birth attendants were asked to describe how they
managed these problems, and many responded with
similar answers. TBAs stated that they would refer the
women to the clinic or hospital, but this was usually
done after the women had been in labor for several
hours. Referral was not routinely used as an option
during pregnancy or early in labor. The time to get to a
clinic if referred ranged from 15 min to more than 8 hr,
but most commonly, clinics or hospitals would be 2–3
hr away. This time was calculated based on using the
most available form of transport, which is the “moto”—a
carriage pulled by a motor cycle. Both TBAs and SBAs
would use traditional practices, most commonly the use
of a firestone (warmed rock) on the belly after birth to
“stop the bleeding,” as well as ice to the head for fever
or the administration of “bark” medicine. Sometimes,
Safe Arrivals  McKellar and Taylor  81
birth attendants would recommend rice wine “until
the pain stopped.” They would also manually remove
the placenta if it was retained. The SBAs used oxytocin,
referred to as “oxy,” if the mother began to bleed. They
were also keen to give paracetamol to the mother and/
or baby if they were unwell.
The question was also asked if they had heard
of mothers who had died during or after childbirth,
although this question was not answered by 51 (33%)
TBAs, 57 (54%) of those who responded stated they
had heard of mothers dying. Although 62 (75%) SBAs
provided an answer to this question, 26 (42%) of these
stated they had heard of women’s death during or after
childbirth. A similar question was asked regarding
whether birth attendants had heard of babies dying dur-
ing or after childbirth, and a similar response rate was
gained, with 60 (57%) TBAs who responded stating that
they had heard of babies dying, whereas 28 (47%) SBAs
knew of babies’ deaths during or after birth.
The questionnaire tried to gain an understanding
of common practices during labor. Care provided was
usually supportive and caring. Most significantly, two
practices were identified that were concerning. Birth
attendants were asked if they assisted with delivering the
placenta and how they did this. There were 149 (96%) of
the TBAs who assisted with the delivery of the placenta,
and most commonly, this was by actively massaging or
rubbing the abdomen. There were 76 (93%) SBAs who
also assisted delivering the placenta in the same manner
but used controlled cord traction as well. They would
only use a form of oxytocin if there was bleeding, but
this was not used routinely. In addition, although the
mothers were able to walk around during labor, birth
attendants were reluctant to allow women to birth in
any other position than lying down on their back. Many
of the birth attendants described the position of the
women during birth similarly to this response from a
TBA, “[they] walk around with little pain, and with big
pain they lie down, put knees up, and don’t move.” A few
SBAs stated they would get the mothers to sit up, and
very few acknowledged they would encourage women
to squat for birth.
Birth attendants were asked about specific r­ ituals
that they employed through the care they provided;
Table 3 provides a summary of these. Although many of
these simply reflected cultural and religious traditions,
there were some that could be potentially harmful such
as minimizing food during pregnancy to reduce dif-
ficulty at birth, as well as the rice wine, which has high
alcohol content and the unknown constituents of the
Khmer tree bark medicine.
82  Safe Arrivals  McKellar and Taylor

TABLE 3  Traditional Practices Associated With Childbirth and Rationale

TRADITIONAL PRACTICE ASSOCIATED WITH CHILDBIRTH RATIONALE

Bamboo tree Sap placed on cord stump to stop bleeding

Khmer tree bark medicine Boil and drink for vitamins
Fire under the bed People die because of cold; therefore, they create a stone
fire under the bed.
Hot stones on belly Help stop bleeding
Drink husband’s urine. Protects from ugliness, stay young
Don’t eat too much during pregnancy. Able to keep baby small
Rice offered to the ancestors/spirits Blessing
Salt and pepper drink Creates thirst and encourages the woman to drink more
Drink alcohol (rice wine) and medicine from Thai tree. Sometimes for pain
Boil and drink coconut and banana. No rationale provided
Ice to belly or head Treat fever

The questionnaire also sought to understand some grandmother was or because they were asked to assist at a
of the psychosocial aspect of being a birth attendant in birth: “My grandmother was and I followed. My neigh-
Cambodia with several questions seeking to understand bor asked me to help deliver the baby.”
what they thought made a “good” attendant at birth In many cases, they began their journey as a birth
and why they became birth attendants (Table 4). Vari- attendant because they were appointed by Khmer Rouge
ous responses were given to these questions with both officials following the genocide in Cambodia in the
SBAs and TBAs acknowledging that being caring and 1970s. The TBAs stated that they were ordered to take
taking care of the mother and baby was their primary on this role, some threatened with their life, and that
role. SBAs also made comments showing an awareness they were often as young as 14–15 years of age, having
of the need for knowledge and training to be able to do no previous experience. “If I didn’t become a midwife,
this well. I would die.”
There were some insightful comments gained Some also identified that there “were not enough
regarding questioning the birth attendants about why in their village,” and another example was that a “fire
they took on this role, and in many cases, this led to had destroyed their hospital, so she just helped,” or they
sometimes lengthy narratives. Commonly for the TBAs, were appointed by a commune leader: “No midwife
there was a sense of expectation that they would take on in the commune—helped with births and now a birth
this role. This may have been because their mother or attendant.”
Some simply just wanted to become one; they
“wanted to care for women and help their country,” and
they “wanted to save lives.”
TABLE 4 Understanding of What Makes a Good
Most commonly for SBAs, there was a degree
Birth Attendant
of choice evident in their decision to become a birth
WHAT MAKES A “GOOD” BIRTH ATTENDANT? ­attendant: “I wanted to become one” and “it was my
SBA TBA ambition.” What was evident, however, was that for
both, there was an evident concern and commitment
Advice Taking good care of the mother
Training and education Check women
to the women of their country and that despite the high
Equipment and hygiene Be able to go to clinic with rate of sickness and death they witnessed, they contin-
woman ued in their role.
Caring, kind Caring, help when pregnant
Get women to the clinic Using soap, good hygiene
Knowing signs of problems Care for baby DISCUSSION
Learn from others
Prepare the mother
The responses to this questionnaire have directly
Note. SBA 5 skilled birth attendant; TBA 5 traditional birth attendant. informed the Safe Arrivals training with further

development of training resources that consider the
local context and a more diligent cultural prepara-
tion of midwives who implement the program. This
supports the notion that it is important to consider
the local cultural context in development of training
needs and is appropriate to tailor the resources to
address these needs and specific practices (Kruske &
Barclay, 2004). Several examples are evident; firstly,
gaining an understanding around the way in which
birth attendants manage third stage directed our
teaching to focus on appropriate practice when
conducting physiological (expectant) third stage.
Although there is still debate in practice regarding
active versus physiological management of third stage
where oxytocics are readily available, there are clear
guidelines in managing the delivery of the placenta
when active management cannot be implemented
(Stables & Rankin, 2010). For example, a hands-off
approach is advocated when no oxytocics drug is
administered. Rubbing and handling of the uterus
during third stage may contribute to hemorrhage or
increase the retention of the placenta (Sinclair, 2004;
Stables & Rankin, 2010; Thorpe & Anderson, 2010).
Notably, hemorrhage and retained placenta were
identified as problems birth attendants face during
birth. The Safe Arrivals program is now more explicit
and detailed in the teaching provided to the atten-
dants about both active and physiological manage-
ment of third stage.
Secondly, identifying that Cambodian women
are encouraged by birth attendants to lie flat on their
back for birth was significant. The training has pur-
posefully incorporated resources, which explain the
implications these might have on birth outcomes. Spe-
cifically, birth attendants are shown different birth-
ing positions and how this may assist with birth. It
is interesting to note that this practice is a difficult
concept for the birth attendants to embrace and is not
necessarily understood or supported by government
health officials who suggest that maybe Cambodian
women do not want to do this. Nevertheless, provid-
ing the birth attendants with evidence-based practice
that can be implemented simply may influence the
outcome of some births. In addition, resources focus-
ing on nutrition have been adapted, incorporating
teaching around safe foods, alcohol consumption, and
healthy eating using local food sources. Also, the final
day of the workshop now has time dedicated for the
participants to work in groups and respond to sce-
narios, which provides an opportunity for the women
to incorporate the knowledge they have gained. This
Safe Arrivals  McKellar and Taylor  83
enables the training midwives to reinforce several of
the practices highlighted.
The findings also highlighted the difficulty for
women to access emergency care when it is needed, and
a substantial focus on early referral has been incorpo-
rated into the training program. The training specifi-
cally teaches birth attendants to encourage their women
to attend their antenatal appointments at a local health
clinic. Officially, the Cambodian Department of Health
recommends that pregnant women attend at least four
visits with an SBA or midwife during their pregnancy.
Although this is encouraged, the training also focuses
on providing TBAs with skills to identify possible
complications during pregnancy and early labor and
explicitly teaches about the importance of early referral
to the local health clinic. TBAs are taught to organize
an emergency transport plan within the local village
to assist the woman to receive skilled and appropriate
care. This specific component of the training has been
further evaluated to ascertain if an increase in referral
and attendance at health clinics has occurred in the
provinces in which this redeveloped training has been
implemented. The results of this evaluation are yet to
be published.
Finally, the findings indicated that 80% of TBAs
visit the women in their care during the antenatal
period and as such, represent a means of access to
women birthing in the rural and remote areas of
Cambodia. Nevertheless, during 2010, the Cambo-
dian government actively discouraged women from
using TBAs for any of their care during pregnancy
and birth. Anecdotally, it has been claimed by several
provincial health officials that there was an increase
in maternal and child deaths and that these were
now occurring at health centers or outside health
centers that were closed (personal communications).
It was also noted that TBAs were reluctant to discuss
poor outcomes unless they could distant themselves
from being held responsible. This is certainly not
only because of the political history and associated
genocide many of these women lived through but
also in response to recent attempts to outlaw TBAs
as a means to manage the high mortality rates.
Despite this, it must be considered, that while there
are insufficient numbers, and a lack of accessibility,
for all women to be attended by a midwife or SBA, it
is important that TBAs are recognized as a valuable
resource for women, acknowledging their social and
cultural role in childbirth (de Bernis, Sherratt, Abou-
Zhar, & Lerberghe, 2003; Dietsch & Mulimbalimba-
Masururu, 2011).
84  Safe Arrivals  McKellar and Taylor
CONCLUSION
As outlined in this article, the responses to the ques-
tionnaire provided a means to focus and improve the
training provided by this NGO for birth attendants in
Cambodia. A commitment by the NGO and Cambo-
dian government to incorporate local understanding
and evidence-based practice ensures ongoing quality
improvements regarding training programs. The find-
ings also identified that TBAs continue to provide
care and support to women during the childbirth con-
tinuum. Acknowledging that TBAs are a vital link in
providing access to women particularly in the remote
provinces of Cambodia may be of significance in future
projects. A specific focus on facilitating a partnership
between midwives, SBAs, and TBAs to increase refer-
ral and access to care in early pregnancy might be a
possible strategy. This is in line with the WHO report
(2005, p. 25) that proposed that “where TBAs are well-
integrated into the community and are well respected,
efforts can be made to redefine their role to become
support workers or health promoters.” Such an approach
would use the accessibility of TBAs and provide a vital
link in facilitating skilled care for every woman. It is
also recommended that there is a need to provide ongo-
ing professional development through evidence-based
trainings to SBAs.
Limitations
This article reports the responses to a questionnaire
developed primarily as a tool to facilitate ongoing qual-
ity rather than a research tool; nevertheless, the findings
from the questionnaire provide valuable insight regard-
ing the experiences of Cambodian women and TBAs
and may provide an important foundation for future
research.
REFERENCES
de Bernis, L., Sherratt, D., AbouZhar, C., & Lerberghe, W.
(2003). Skilled attendants for pregnancy, childbirth and
postnatal care. British Medical Bulletin, 67, 39–57.
Dietsch, E., & Mulimbalimba-Masururu, L. (2011). The expe-
rience of being a traditional midwife: Living and work-
ing in relationship with women. Journal of Midwifery &
Women’s Health, 56(2), 161–166.
Kruske, S., & Barclay, L. (2004). Effect of shifting policies on
traditional birth attendant training. Journal of Mid-
wifery & Women’s Health, 49(4), 306–311.
Kurjak, A., & Bekavac, I. (2001). Perinatal problems in devel-
oping countries: Lessons learned and future challenges.
Journal of Perinatal Medicine, 29(3), 179–187.
MacArthur, C. (2009). Traditional birth attendant training for
improving health behaviours and pregnancy outcomes:
RHL commentary. The WHO Reproductive Health
Library. Geneva, Switzerland: World Health Organi-
zation. Retrieved from http://apps.who.int/rhl/preg-
nancy_childbirth/antenatal_care/general/cmacom/en/
index.html
Sinclair, C. (2004). A midwife’s handbook. St. Louis, MO:
Saunders.
Stables, D., & Rankin, J. (2010). Physiology in childbearing.
London, United Kingdom: Elsevier.
Thorpe, J., & Anderson, J. (2010). Supporting women in
labour and birth. In S. Pairman, S. Tracey, C. Thoro-
good, & J. Pincombe (Eds.), Midwifery: Preparation
for practice (2nd ed., pp. 505–506). Sydney, Australia:
Elsevier.
Ugal, D. (2010). Household environment and mater-
nal health among rural women of Northern Cross
River State Nigeria. Journal of Medical Humani-
ties & Social Studies of Science and Technology,
2(2), 4. Retrieved from http://www.ea-journal.com/
numeros-anteriores/62-vol-2-n-2-diciembre-2010
United Nations. (2008). The Millennium Development Goals
report 2008. Maternal deaths per 100,000 live births,
1990 and 2005. Retrieved from http://www.undp.org.
af/Publications/KeyDocuments/MDG_Report_2008
_En.pdf
United Nations Population Fund. (2011). State of the world’s
midwifery report: Delivering health, saving lives. New
York, NY: UNFPA:. Retrieved from http://www.unfpa.
org/sowmy/report/home.html
World Health Organization. (1992). Traditional birth atten-
dants—A joint WHO/UNFPA/MCH statement. Geneva,
Switzerland: Author. Retrieved from http://whqlibdoc.
who.int/publications/1992/9241561505.pdf
World Health Organization. (2005). Skilled care at every birth.
New Delhi, India: WHO Regional Office for South-East
Asia. Retrieved from http://www.searo.who.int/EN/
Section1430/Section1439/Section1638/Section1889/
Section2075_10436.htmhttp://www.who.int/maternal_
child_adolescent/documents/MPS_factsheet_ensur-
ing_skilled.pdf
World Health Organization, United Nations Children’s Fund.
(2010). Maternal, newborn & child survival Cambodia.

Retrieved from http://www.countdown2015mnch.org/
documents/2010report/Profile-Cambodia.pdf
Yanagisawa, S., Oum, S., & Wakai, S. (2005). Determinants
of skilled birth attendance in rural Cambodia. Tropical
Medicine & International Health, 11(2), 238–251.
Acknowledgments. No official funding was provided. Local
fundraising in Adelaide by The 2h Project was conducted.
The authors would like to acknowledge Heng Piseth, direc-
tor, Smile of World; the Cambodian women who participated
in the study; Australian midwives who provided the training
and undertook the interviews; and the Cambodian Ministry
of Health.
Safe Arrivals  McKellar and Taylor  85
Correspondence regarding this article should be directed to
Lois V. McKellar, PhD, BN (hons), BMid, Grad. Cert. Int.
Stud., Midwifery, The University of South Australia, School of
Nursing and Midwifery, City East Campus, Frome Rd., South
Australia, 5000. E-mail: lois.mckellar@unisa.edu.au
Lois V. McKellar, PhD, BN (hons), BMid, Grad. Cert. Int.
Stud., program director, Midwifery, School of Nursing and
Midwifery, The University of South Australia.
Kevin Taylor, M. Int. Comm. Devel., executive director, The
2h Project.
Immigrant New Mothers in Finnish Maternity
Care: An Ethnographic Study of Caring
Anita Wikberg, Katie Eriksson, and Terese Bondas

PURPOSE:  To illuminate experiences and perceptions of caring in the maternity care culture of immi-
grant new mothers in Finland.
DESIGN:  This is a descriptive interpretive ethnography.
PARTICIPANTS AND SETTING:  Seventeen new mothers from different cultures on a maternity ward
in a medium-sized hospital in Finland.
METHODS:  Focused ethnographic analysis and interpretation of interviews, observations, and field
notes were used.
FINDINGS:  Caring was part of the positive experience of childbearing and beneficial for the health
and well-being of the immigrant new mothers. Negative experiences of health care impaired their
well-being. The resources of Finnish maternity care and cultural knowledge of the nurses facilitated
the ­caring. The policy and attitude of Finnish society encouraged childbearing. The immigration regu-
lations affected support during childbearing negatively and tended to caused loneliness. The Finnish
maternity care was not fully adapted to the mothers’ wishes to understand the organization of Finnish
maternity care, to communicate, to breastfeed, and to have family-centered care, a flexible length of stay
in the hospital, and extended support after childbirth.
CONCLUSION:  Caring improves the childbearing experience and the well-being and health of new
immigrant mothers; therefore, caring needs to be emphasized in maternity care, health care administra-
tion, and nursing education.
KEYWORDS:  intercultural caring; health; suffering; maternity; immigrant women; Finland

INTRODUCTION health and well-being (Eriksson, 2002; Leininger,

In an increasingly multicultural world, more women
from different cultures are entering maternity care.
In this study, the perspective of immigrant women
who come from different cultures, and give birth in a
new culture, are studied. Caring has been described as
the core of nursing (Eriksson, 2002; Leininger, 2006).
These internationally known theorists describe caring
as encompassing love, hope, listening, understanding,
respect, presence, and comfort, among others. The
presence of caring has been described as promoting
2006). In nursing care for people of other cultures,
the absence of caring or noncaring has been described
as hurt dignity (Heikkilä & Ekman, 2000), insensitiv-
ity and prejudice (Davies & Bath, 2001), and racism
and discrimination (Browne & Fiske, 2001; J­ ohnstone
& Kanitsaki, 2009; Tebid, Du Plessis, Beukes, van
Niekerk, & Jooste, 2011). Noncaring leads to the
avoidance of health care services and disrupted nurs-
ing care relationships, which indirectly can cause
higher morbidity and mortality (Berggren, Bergström,
& Edberg, 2006).

INTERNATIONAL JOURNAL OF CHILDBIRTH Volume 4, Issue 2, 2014

© 2014 Springer Publishing Company, LLC www.springerpub.com
86 http://dx.doi.org/10.1891/2156-5287.4.2.86

In Finland, young immigrant women between
15 and 29 years of age are the only immigrant group
using more health care because of pregnancy and
birth than the Finnish majority (Gissler, Malin, &
Matveinen, 2006). However, perinatal mortality is
considerably higher among babies born to moth-
ers from Africa, including Somalia (Malin & Gissler,
2009). Similar findings are found in Sweden (Essén
et al., 2000; ­Robertson, 2003) and Norway (Vangen,
Stoltenberg, & Stray-Pedersen, 1999), showing that
immigrant mothers receive suboptimal care and have
more health problems compared to the majority popu-
lation. According to O’Mahony and Donnelly (2010),
immigrant mothers have a higher risk of postpartum
depression. However, if following cultural traditions,
for example, “doing the month,” the risk is lower. It has
been suggested that European midwives and obstetri-
cians should pay attention to the challenges of cultural,
as well as medical, competence when caring for immi-
grant women (Elebro, Rööst, Moussa, Johnsdotter, &
Essén, 2007).
Brämberg and Nyström (2010) claim that the
whole life history of immigrants affects their situation,
which influences their activity and participation in
health care situations. They suggest that it would be
essential to consider the life situation of immigrants
instead of just their cultural background. Lack of
knowledge and information about expectations ­during
the childbearing of women with different cultural
backgrounds might lead to the insensitive and inef-
fective cultural care of these women (Brathwaite &
­Williams, 2004).
Maternity care and the experiences of mothers
in different cultures have been studied extensively.
Lamp (1998) studied the meanings of generic and
professional culture care and practices in Finnish
childbirth, whereas Bondas (2000) studied the expe-
rience of Finnish women being pregnant and giving
birth. The meaning of childbirth to Finnish women
was studied by Callister, Vehviläinen-Julkunen, and
Lauri (2001). Few qualitative studies on immigrant
mothers’ experiences of caring in Finnish maternity
care culture were found (cf. Adjekughele, 2003; Ban-
jara, 2011; Wikberg, Eriksson, & Bondas, 2012). Com-
mon findings in these studies were language problems
and insufficient information that sometimes influ-
enced health negatively. The mothers thought that the
maternity care was of high quality and accessible to
everyone who had a health insurance card. The moth-
ers, however, missed support from their extended
Immigrant New Mothers in Finnish Maternity Care  Wikberg et al.  87
family, and family-centered care was not emphasized
enough, even though the fathers were allowed to take
part. Differences in expectations and experiences of
caring in Finnish maternity care have been described
(Wikberg et al., 2012), as well as stereotypes and the
ethnocentric views of nurses. Finnish maternity care
traditions were sometimes imposed on the immigrant
mothers. However, the professional nurses were seen
as friends and conflicts were solved. The cultures of
the mothers, as well as the Finnish maternity care cul-
ture, influenced the caring. Caring was related to the
changing culture.
Malin and Gissler (2009) call for qualitative
­studies on the experiences of birth and care of ethnic
minority mothers that could possibly explain higher
perinatal mortality and morbidity among immigrants
in Finland. They suggest that “non-Western women
might be at risk of discrimination and deprivation
based on gender, class and ethnicity” (Malin & Gissler,
2009, p. 12). Because caring seems to play an impor-
tant role for a positive childbearing experience, it is
essential to study how women from other cultures
experience caring during childbearing in a country
such as Finland with high-quality maternity care.
Childbearing includes pregnancy, labor, and the post-
partum period.
PURPOSE
The purpose is to illuminate the experiences and per-
ceptions of caring in the maternity care culture of
immigrant new mothers in Finland. This ethnography
focuses on caring in maternity care during childbear-
ing from the point of view of immigrant new mothers.
This study is part of a project called Encountering the
Unknown in Health Care.
THEORETICAL PERSPECTIVE
The theoretical perspective is the caritative caring
theory and caring science tradition (Eriksson, 2002,
2006; Lindström, Lindholm, & Zetterlund, 2006). This
means that the mother is seen as an entity of body, soul,
and spirit. She is both unique and part of a community,
where family and friends are important. Caring can
take many forms and expressions. Respect for the
dignity of the woman as a human being, genuine com-
88  Immigrant New Mothers in Finnish Maternity Care  Wikberg et al.
munion with health care professionals, and an under-
standing of the human being is the ethos underlying
caring. Caring is the core of nursing care, which alle-
viates suffering and promotes health and well-being.
Not only the mother’s physical and mental health is
considered but also her well-being. The caring sci-
ence tradition not only describes what is experienced
but also tries to find deeper understanding through
interpretation. Health and suffering are two sides of
human life. The mother’s health and well-being can
be compatible with endurable suffering. The mother
strives for health and well-being but might experience
suffering. Health and suffering contain doing, being,
and becoming. Suffering can be described as a drama
with three acts, where the nurse confirms the suffer-
ing of the woman, allows the woman time and space
to suffer, and allows the woman to reconcile with the
situation. The suffering of an immigrant mother can
be caused by illness, life, and violation or noncaring in
health care. Life refers to the situation of immigration
as well as becoming a mother.
The caring science tradition earlier is the foun-
dation of intercultural caring (Wikberg & Eriksson,
2008; Wikberg & Bondas, 2010; Wikberg et al., 2012).
Intercultural caring refers to a genuine relationship
between the nurse and the patient from different
cultures that are seen as equal. Caring is seen in four
different dimensions: universal, cultural, contextual,
and unique. Outer factors as well as the inner core of
caring are important for the experience of caring. Car-
ing strives to alleviate suffering and improve health
and well-being. Culture refers to “a pattern of learned
but dynamic values and beliefs that give meaning to
experience and influences the thoughts and actions of
individuals of an ethnic group” (Wikberg & Eriksson,
2008, p. 486).
SETTING
The setting is Finland, a Nordic country. During the
past 20 years, immigration has increased more than
six times in Finland (Statistics Finland, 2012). In 2010,
there were 167,954 (3.1%) foreign nationals in Finland.
In the same year, there were 224,388 (4.2%) persons
speaking a language other than the national languages
of Finnish (90.4%), Swedish (5.4%), and Sámi (0.03%)
as their mother tongue. The most common foreign lan-
guages spoken were Russian, Estonian, English, Somali,
and Arabic. Most foreign-born (64.6%) were from
Europe, 19.8% were born in Asia, and 9% in Africa.
The foreign population in Finland is younger and has
higher fertility rates than the Finnish population (Malin
& Gissler, 2009).
The Finnish health care system supports maternal
and child health. The service is paid for by taxes and is
free of charge for patients. The patient pays a n ­ ominal
fee only for hospital and outpatient clinical visits.
During pregnancy, practically all mothers, including
immigrants, visit a public health nurse or midwife at
an antenatal clinic regularly, on average, 15.6 visits in
2010 (National Institute for Health and Welfare, 2011a).
Women also see a medical doctor three times during
pregnancy. Mothers who live in Finland and are cov-
ered by the Finnish social security system are entitled
to a maternity grant if they register with maternity
care before the end of the fourth month of pregnancy
(Kela—The Social Insurance Institution of Finland,
2011). Mothers are entitled to maternity and parental
leave and an allowance of 105 plus 158 days. Either
parent can use the latter. In addition, fathers can take
paternity leave and an allowance of 1–18 days. Almost
all babies are born in hospitals assisted by a midwife,
but pediatricians and obstetricians are readily avail-
able if complications occur. After delivery, the mother
and the baby stay in hospital on average for 3 days and
are then referred back to the health center, where the
public health nurse or midwife continues the care of the
mother and baby. Home visits are also made. Refugees
have the same rights as Finnish nationals, whereas asy-
lum seekers have a more restricted access to health care.
Both groups are offered maternity care and interpreters
free of charge and have organizations that assist them. In
2010, maternal mortality (4.9 out of 100,000) and peri-
natal mortality (4.0 out of 1,000) in Finland (National
Institute for Health and Welfare, 2011a, 2011b) were
among the lowest in the world.
The maternity ward in Western Finland, where
the study was conducted, has about 1,400 deliveries
a year. The ward has a philosophy of care, including
family-centered care, being baby-friendly, supporting
breastfeeding, striving for a satisfied and safe family,
encouraging self-care, individuality, and support of
motherhood. Nurses in this study refer to public health
nurses, midwives, and auxiliary pediatric nurses. Car-
ing refers to the interpersonal relationship between a
nurse or doctor and a mother, whereas care refers to
the organization of the health system. Maternity care
is part of health care, which refers to both medical and
nursing care.
 Immigrant New Mothers in Finnish Maternity Care  Wikberg et al.  89

TABLE 1  Information About Participants and Method

COUNTRY REASON FOR TIME IN NUMBER OF INTERPRETER NUMBER OF
OF BIRTH ­IMMIGRATION FINLAND RELIGION AGE CHILDREN AT INTERVIEW OBSERVATIONS

 1 Australia Marriage 8–9 years Christian 28 1 — 2

 2 Bosnia Work, family 2 years Muslim 19 1 Husband 1
 3 Bosnia Work, family 5 years Muslim 32 3 — 2
 4 Bosnia Work, family 2 years Muslim 27 1, pregnant Professional —
interpreter
 5 Burma Refugee 8 months Christian 19 1 Professional 3
interpreter
 6 Colombia Studies 3 years Christian 36 2 — 1
 7 Estonia Family 1.5 years — 20 1 — 2
 8 Estonia Marriage, work 8 years — 32 3 — 2
 9 Estonia Work 3 years — 32 2 — 1
10 Hungary Work 2 years, Christian 25 1 Professional 2
5 months interpreter
11 India Work, family 5 years Hindu 31 2 — 3
12 Iraq Refugee 10 years Muslim 28 3 — 3
13 Iraq, Asylum seeker, family 2 years Muslim 22 2 Professional 3
Kurdish reunification interpreter
14 Russia Work 4 years — 33 1 — 1
15 Thailand Marriage 1.5 years Buddhist 28 4 Husband —
16 Uganda Marriage 2 months Christian 34 1 — 3
17 Vietnam Marriage 1.5 years — 23 1 Husband 1

PARTICIPANTS 2008) was used. The thematic guide included questions

There were 17 first-generation, immigrant new ­mothers
who participated in the study (see Table 1). One mother
was pregnant. The other mothers had given birth
1–3 days ago. There are 3 mothers with previous
­children who delivered in Finland for the first time.
The ­educational level, occupation, and employment of
the mothers varied. An additional 3 mothers declined
to p­articipate, and 6 were not included because no
interpreter was available, one mother was too young to
participate, and in one case, the nurses forgot to inform
the researcher. However, 12 Finnish female nurses and
pediatricians took part in the care situations that were
observed, and 7 fathers took part in the interviews or
care situations observed.
METHODS
This ethnographic study is focused on caring from the
inside perspective of immigrant new mothers. A the-
matic guide based on previous studies on intercultural
caring (Wikberg & Bondas, 2010; Wikberg & Eriksson,
about caring, health and well-being, and external cir-
cumstances. Questions were both general and specific.
The mothers were asked to tell about their experience
of the care and the caring they had received during
childbearing and to explain what they meant by or to
give an example of what they said. The interviews were
conducted in Finnish, Swedish, or English by the first
author (AW) with the help of four professional interpret-
ers and three fathers (see Table 1). All the mothers were
interviewed once and 15 were observed. Unstructured
observations (Mulhall, 2003) were conducted during the
nursing encounters. Field notes and other documents,
except medical files, were also used. The interviews
were recorded and transcribed verbatim in the language
of the interview; the observations were written down as
soon as possible, and field notes were written and docu-
ments collected alongside the study. The analysis and
interpretation were inspired by Nikkonen, Janhonen,
and Juntunen (2001), Roper and Shapira (2000), Sprad-
ley (1979), and Geertz (1973). The transcribed data were
read and reread and categorized to form themes. First,
the data of each mother and then the data of all the
mothers were analyzed and interpreted together. Finally,
90  Immigrant New Mothers in Finnish Maternity Care  Wikberg et al.
the themes were examined to find patterns (Roper &
Shapira, 2000) that explained and illuminated the moth-
ers’ experiences of caring in the Finnish maternity care
culture. Quotations were used as examples of patterns.
Finnish and Swedish quotations were translated into
English and back-translated by a different person so as
not to lose any meaning.
Ethical Considerations
The Finnish National Advisory Board on Research Eth-
ics (2002, 2009) has been followed. Permission to con-
duct the study was granted from the ethical committee
of the hospital. All the participants were given verbal
and/or written information about the study. They were
informed about voluntary participation, confidentiality,
and the possibility to withdraw without any explanation
or influence on their care. Written consent was received
from all the participants. A small gift was given to all the
mothers after the interview.
FINDINGS
The findings presented are six patterns interpreted from
the data to illuminate the immigrant new mothers’
experiences and perceptions of caring.
Caring Was Beneficial for Health and Well-Being
The mothers said that the care they had received
had been good for them and their baby’s health and
well-being. The mothers described how regular and
thorough checkups, examinations, and tests were good
for them and their baby’s physical health. A mother of
three said,
Really good, really good . . . always at antenatal
clinic, time to check baby’s heartbeat and blood
pressure and everything . . . this weight, the . . . of
the belly [shows how to measure] . . . This always
comes . . . and the mother can be calm . . . and
know everything is going well.
Nothing was missed in the antenatal clinics, and
special health concerns such as premature uterine con-
tractions, thyroidal problems, or high blood sugar were
attended to.
The mothers said that it felt good to meet the
nurse at the antenatal clinic or at the hospital. This
was described as having a psychological effect on the
health of the mother, even though the mothers thought
their basic health was the same as before, or it had
improved during the pregnancy or stay in Finland. They
mentioned relevant information and advice they had
received from the nurses. Friendly nurses who had time
for them made the mothers want to attend the antenatal
clinic. When the nurses really wanted to help them and
their babies, it also affected their well-being positively
and made life easier. The mothers said that the care they
had received was good for their health, but the preg-
nancy and delivery itself affected their health negatively,
for example, weight gain or pain during the delivery or
from perineal sutures after the labor.
The mothers talked about their baby’s health
­during pregnancy, delivery, and afterward. During preg-
nancy, the mothers were worried that it would end in a
miscarriage, that the baby would be born too early or
die, or that the baby would be damaged at birth. The
tests and examinations usually reassured and calmed
them. If the nurse or doctor doing the ultrasound did
not say anything, they became alarmed that something
was wrong. Another mother of three said,
Now it was good when here is ultra [sound]; it
was really nice . . . when you could see everything
yourself and she explained really well what it
is—hands, brain, heart, and everything . . . there
[other place] you just lay down, and I remember
there was a man, he just examined me, but he
did not say anything; I always had a panic that
“is everything alright?” and you could not see
anything; he gave a few pictures and said “every-
thing is ok,” but now I had a real good feeling . . .
After delivery, the mothers were worried that they
would not get help if they needed it. They were worried
that they would not be able to take care of the baby and
that their milk would not be enough, and they had no
one to ask. The mothers felt the hospital was safe, and
the nurses and doctors would know what to do if some-
thing went wrong. These mothers had visited delivery
wards during pregnancy or emergency rooms with their
newborn when they panicked about the health of their
baby, and they got help. The mothers who had delivered
children in Finland before felt more comfort in knowing
that they could call the nurses, who were there for them.

Negative Experiences of Health Care or Traumatic
Memories Made the Mothers Suffer
Those mothers who did not get the information or
support that they needed because of language prob-
lems or the attitudes of the nurses did not like to go to
the antenatal clinic in the beginning. This made them
frustrated. A mother of two felt that she had received
misleading advice and the wrong recommendations
about diet at the antenatal clinic, which resulted in
health problems later on. Mothers who were not given
information in a language they could understand or felt
that their dignity was not respected in the beginning did
not enjoy the relationship with the nurse. A first-time
mother said,
I had disagreements with the nurse at the ante-
natal clinic during the pregnancy . . . In the end,
I got all the answers . . . In the beginning, the
problem was that I did not understand why the
nurse did not want to understand that I had fear,
even if it was the same nurse, already then, when
I had those [earlier complications] . . .
A mother of two had a traumatic memory of her
first delivery in Finland, where both she and her baby
had health problems. When complications occurred
during delivery, the nurse did not listen to her; the
mother received no information and had to guess from
the little language she understood. Facial expressions
and the body language of the nurses and doctors made
her understand that there was something seriously
wrong.
. . . and suddenly, there were a lot of people
around . . . eight or nine people, doctors and
nurses, and their faces were like horror . . . and
they told my husband, “you have to go out.” . . .
but they never told me anything.
After delivery, the mother had more complica-
tions. Because of this, she was unable to take care of
the baby, who also needed special care. She could not
see her baby often and felt that she was treated badly.
This was experienced as having a negative influence
on her health and well-being. She did not receive any
explanation as to why things went wrong and why
procedures were done the way they were. This affected
Immigrant New Mothers in Finnish Maternity Care  Wikberg et al.  91
her mentally so much so that she became very scared
of childbirth. During the next pregnancy, this was,
however, corrected, and the most recent delivery was a
good experience.
A first-time mother said she was afraid of hospi-
tals because of previous experiences of losing someone
in her native country.
. . . I personally have a phobia for hospitals; it
just scares me . . . [sighs deeply] yeah, [the voice
almost cracks]. Probably, . . . ok, back home,
maybe the fact that you go to a hospital and you
probably lose somebody there. You just have this
feeling; it’s just not a good feeling, so you keep
kind of remembering it.
The mothers mentioned that they did not want
to or could not speak about everything with the nurses
but saw it as their own responsibility to tell. A mother
of three said, “for example, they [the nurses] don’t know
that something has happened, and others [mothers] can
tell that the nurses have not helped them, but if you do
not tell, so it is your responsibility.”
The Economic Resources and Education of
the Nurses Facilitated Caring for Immigrant
New Mothers
The mothers mentioned the economy. A first-time
mother feared becoming pregnant when there was an
economic recession in Europe. She said,
. . . perhaps the recession . . . because it affects
psychologically . . . If you discuss it and problems,
might come, it is not connected to care, but it
affects this . . . my own nerves, sometimes. I am
pregnant and now this strikes . . . How it affects,
that is, can I support my own child? . . . and I
think it is for everybody . . .
The mothers thought good quality maternity
care was not expensive in Finland. There were more
nurses and doctors in Finland than in their country of
origin. The mothers also mentioned a better personal
economy. In the antenatal clinics and hospitals, all
that the mothers needed was available; there was no
92  Immigrant New Mothers in Finnish Maternity Care  Wikberg et al.
shortage of resources or materials. A mother of three
said,
. . . and you do not need to have a lot of things
because here are [showing her nightdress] . . .
nightdress and gown . . . and there [in country of
origin], there is nothing, but you have to [search-
ing for words] . . . bring your own.
The mothers mentioned maternity, paternity, and
parental leave and allowance and the maternity grant,
a package with baby clothes or cash benefit, from the
Social Insurance Institution of Finland as positive things.
A first-time mother said that the good education
of the nurses also affected the nursing care and caring
positively. Others talked about maternity care profes-
sionals as experts. The mothers mentioned and it was
also observed that the nurses knew some of the cultur-
ally specific needs of the immigrant new mothers.
The Policy and Attitude of Finnish Society
Encouraged Childbearing
The mothers were really grateful for being able to live in
Finland. They hoped to learn the language and get an edu-
cation in the future. The society felt safe, and this encour-
aged their decision to have a baby. A first-time mother
said, “It feels much safer here in Finland and calmer than
in [country of origin] . . .” Maternity care is available
equally for everybody. A mother of three mentioned the
Act on the Status and Rights of Patients ­(Finlex, 1992),
which states that everybody is entitled to good quality
health care. The mothers also mentioned that there is a
positive attitude toward children in the country. Another
first-time mother said, “You cannot lose your job because
you get pregnant.” Day care is available and children are
welcome everywhere. She continued,
I think . . . that people want to have children
in Finland. In some way, they are not welcome
any more in [country of origin], in restaurants.
[Here] there is day care everywhere and you
don’t have to book day care already before they
are born . . . to get a place.
She continued that maternity leave promotes
breastfeeding.
. . . but you do not have time to breastfeed [in
country of origin] if you have to go back to work
then . . . It is actually quite few that breastfeed .
. . but here, it is like clear that everybody should
breastfeed. I think it is good. . . .
The mothers also said that fathers are allowed to
take part in the maternity care. A mother of three said,
“In my country you cannot get a support person; like the
husband cannot be with you, and no (grand)mother.”
Fathers usually took part in both antenatal clinics and
delivery and visited after delivery. Some fathers were
unable to be at the antenatal clinics because of their
work. However, fathers were sometimes rejected and
excluded by the nonverbal body language of nurses in
the hospital. According to an observation, the nurse
turned her back on the father when talking to and
assisting the mother with breastfeeding. The father took
his jacket and left the room. Other fathers were asked
to interpret, make the bed, or heat the bottle or make
sure the baby was bottle-fed. The father’s experiences
of childbirth or becoming a father were not discussed.
A first-time mother also thought that the govern-
ment controls the people by paying for the health care
and especially by using social security numbers. On the
other hand, she liked the fact that nobody can cheat or
disappear in the health care system.
Immigration Regulations Negatively Influenced
the Loneliness of the Mother and Her Support
During Childbearing
The mothers missed their family members, especially
their mothers and sisters. Some accompanied them in
maternity care. In both interviews and observations, it
became clear that if the mothers or mothers-in-law were
living in Finland, they assisted and advised and some-
times made decisions for the new mothers. A (grand)
mother wanted to visit her daughter during childbear-
ing but was not granted a visa. A mother of two said,
. . . everything is nice, but one thing is . . . my
mum, she did not come here, so I am a little bit
[laughs but looks unhappy]. Researcher: Are you
sad because of that? Mother: Yes, my dad, he
came here, but my mum [sounds sad and long-
ing, almost crying]. Father: She could not come
because some paperwork [visa] was not ok.

The mothers said that the grandparents helped
them with child care in their country, but here, they
had no one. Some had family, or countrymen, but some
were alone with their husband. One first-time mother’s
husband was still in a refugee camp without a permit to
enter the country. She said, “I am here alone giving birth
to the first child, so . . .” However, another f­irst-time
mother also mentioned that the advice from relatives
was not appropriate in Finland, and therefore, she
became more worried when listening to them.
Finnish Maternity Care Was Not Adapted to the
Immigrant New Mothers
Maternity care was organized differently in differ-
ent countries. Some of the mothers had difficulties
in knowing where to go and whom to talk to when
becoming pregnant in Finland. All the mothers were
not used to nurses being responsible for normal preg-
nancies and deliveries. The mothers felt disappointed
in the beginning because they did not meet a doctor at
each appointment, but in the end, they appreciated the
good quality of nurse-led antenatal clinics. A first-time
mother said, “. . . caring was good or excellent, but the
system was not clear.”
The amount and timing of, for example, mater-
nity leave and tests were different. The mothers would
have liked to have more ultrasound examinations. They
thought it was good for the baby’s health to check the
baby more often, and it made them happy to see the
baby each time. A first-time mother said,
Each time I would go to the hospital like for the
monthly periodic checks, I would have antenatal,
and they would do my . . . ultrasound. Yes, so they
would check the baby’s state and everything, but I
noticed that when I came here, it’s not, not a regu-
lar thing to do ultrasounds, which I thought was
not good, ‘cause sometimes you can’t know what is
happening to your baby and yet . . . probably . . .
a problem going on in there . .
Information from the antenatal clinic to the hospi-
tal and vice versa was not always transmitted smoothly,
according to the mothers. The mothers said that they
sent text messages as soon as they had delivered to the
nurse in the antenatal clinic because this was faster
Immigrant New Mothers in Finnish Maternity Care  Wikberg et al.  93
than to wait for a letter from the hospital. The mothers
thought they went more often to antenatal clinics than
they would have done in their own country because the
next appointment was automatically given or they had
knowledge from previous pregnancies.
The mothers enjoyed having their own delivery
room safeguarding their privacy. A mother of three
said,
. . . I have to say, the nursing care is really good
here in Finland. . . . . from where I come from, it
is a big difference that I can say . . . for example
in [country of origin] when you come to the
hospital to deliver, then many young women
[deliver] in one room so . . . I can watch another
woman deliver and here . . . Everybody has their
own room.
However, mothers would have liked to have their
husbands or other family members with them all the
time after the delivery in the hospital. This was not
possible because there were no family rooms in the
maternity ward. Some of the mothers also wished to stay
longer in the hospital to become used to caring for the
baby, in particular, to manage breastfeeding as well as
to rest and recover. These mothers were worried about
going home because they had no relatives to ask ques-
tions from.
According to interviews and observations, the
rules seemed to be flexible or not fixed. Sometimes,
for example, information about the sex of the baby
at ultrasounds was received, visiting hours were
extended, family rooms were arranged, and sometimes
not. During the summer, the mothers complained of
a disruption of continuity with inexperienced tem-
porary nurses at the antenatal clinics. A mother of
two had met a doctor at the antenatal clinic who was
disorganized, could not find equipment, and told her
that there was no time to answer her questions because
of the workload that day. She thought the appointment
could have been rescheduled instead of blaming her
for the mess. Mothers who had no common language
with the nurse thought it was difficult to communicate
and get information because interpreters were not
used or not available. However, several mothers were
impressed by the ability of the nurses and the doctors
to serve them in three languages (Finnish, Swedish,
and English) in the hospital. A mother also had dif-
94  Immigrant New Mothers in Finnish Maternity Care  Wikberg et al.
ficulty filling in forms because she did not know the
Latin alphabet very well.
The six patterns presented in this study showed
that the mothers were grateful for the high-quality
maternity care they had received during pregnancy
and childbirth. The mother’s caring experiences had
a positive influence on their health and well-being,
whereas noncaring experiences, including a lack of
cultural knowledge and traumatic memories, caused
suffering. The accessibility to care and caring was
influenced by external circumstances such as economy,
education, policy, laws, and the organization of mater-
nity care.
DISCUSSION
This ethnographic study illuminates the experiences
and perceptions of caring by immigrant new mothers
in the maternity care culture of Finland. This study
did not examine mothers from a specific culture or
compare different cultures but rather the perspective of
immigrant new mothers giving birth in a new culture
different from their own. Similar studies on the experi-
ences of women of several African (Murray, Windsor,
Parker, & Tewfik, 2010) and Asian (Hoang, Le, & Kil-
patrick, 2009) cultures giving birth in Australia have
been found.
From the descriptions of the mothers and the
observations, it was clear that the physical health of
the mothers and babies was emphasized most in the
care. It seemed almost as if the baby’s health was more
important for the mothers than their own health. The
mothers appreciated thorough checkups (cf. Bondas,
2002; Shafiei, Small, & McLachlan, 2012). However, the
mothers said that the nurses cared for them and asked
“how they felt and managed with the baby,” which made
the mother feel well and enjoy going to the antenatal
clinic (cf. Carolan & Cassar, 2010; Small, Liamputtong
Rice, Yelland, & Lumley, 1999; Wikberg et al., 2012),
as well as developing their identity as mothers (Ny,
­Plantin, Karlsson, & Dykes, 2007). Spiritual issues were
not discussed according to the mothers in this study,
but sometimes during observations, the admiration and
discussion of the wonder of the birth of the child created
a special moment.
Other mothers felt lonely and isolated because
they had no relatives around or could not understand
the nurses, which made them frustrated, insecure, or
scared. If interpreters were not available or arranged,
they did not get information and knowledge (cf. Ban-
jara, 2011; Lyberg, Viken, Haruma, & Severinsson,
2012). Suffering occurred when they did not get the
support they needed or their dignity was hurt when they
were not listened to or they did not get answers to their
questions. Not listening to the mother or not arranging
interpreters as well as not understanding the culture of
the mother or having prejudice toward the immigrant
new mother or her partner can be compared to suffer-
ing caused by nursing care (cf. Eriksson, 2006) because
of cultural incompetence or intolerance. The immigra-
tion situation itself can be seen as a suffering of life (cf.
Eriksson, 2006). Even if the woman voluntarily leaves
her country, she misses her family, friends, and culture.
Resettlement might have priority over pregnancy (Caro-
lan & Cassar, 2010). Although pregnancy and birth are
not considered an illness, the ailment during pregnancy,
pain during childbirth, and body changes after the
birth can be compared to the suffering of an illness (cf.
­Eriksson, 2006).
In this study, some of the mothers revealed part
of their painful past life histories, but several mothers
from crisis areas declined to take part in the study, and
some started to cry when kindly asked if they wanted to
participate. Some of the mothers who did not want to
or could not reveal everything to the nurse might also
have had difficult memories. Traumatic experiences in
the past might affect the mother’s present childbearing
experience (cf. Lyberg et al., 2012). The mothers might
visualize “all sorts of horrible pictures” (Eliasson, Kainz,
& von Post, 2008, p. 504) if they do not understand
the language and only see the facial expressions of the
nurses. Therefore, it is vital to use professional inter-
preters to give the mother the possibility to disclose
traumatic memories, especially if she is coming from
regions with war, catastrophe, or crisis, where rape, tor-
ture, and other forms of suffering might have occurred
(Correa-Velez & Ryan, 2012).
The caring, which was expressed in the relation-
ships with the nurse, had given the mothers a positive
childbearing experience, which was described as being
good for their health and well-being, wheras noncar-
ing had brought about suffering and was experienced
as decreasing their health and well-being. This is,
however, not different from mothers giving birth in
their own culture (cf. Callister, 2012; Eliasson et al.,
2008; Hunter, Berg, Lundgren, Ólafsdóttir, & Kirkham,
2008). Caring and noncaring experiences during the
childbearing period have lifelong significance for
the woman (cf. Beck, 2006; Forssén, 2012; Hallgren,

Kihlgren, & ­Olsson, 2005; Lundgren, Karlsdottir, &
Bondas, 2009).
External circumstances affect caring either posi-
tively or negatively. In this study, none of the mothers
mentioned difficulties with transportation ­(Correa-Velez
& Ryan, 2012; Hill, Hunt, & Hyrkäs, 2012); long waiting
times and child care (Correa-Velez & Ryan, 2012) costs
(Beine, Fullerton, Palinkas, & Anders, 1995); or lack
of resources, including shortage of personnel to access
maternity care (Shafiei et al., 2012). Instead, it was the
availability of interpreters, organization of the maternity
care, as well as immigration regulations that affected
their possibility to receive good care, have a good child-
bearing experience, and achieve health and well-being.
Private rooms during labor, the acceptance of husbands
or support persons during labor, the availability of spe-
cial diets and antenatal preparations courses, including
visits to the hospitals, were all highly appreciated. The
mothers found the maternity care to be of good quality
and inexpensive.
The mothers were expected to adapt to the mater-
nity care system (cf. Lyberg et al., 2012; Lyons, O’Keeffe,
Clarke, & Staines, 2008). Research has shown that
immigrant mothers in Finland use antenatal services
similarly to Finnish mothers (Malin & Gissler, 2009),
which is not the case in other countries (cf. Choté et
al., 2011). The free access to maternity care and the
requirement to visit the antenatal clinic before the end
of the fourth month to be entitled to the maternity grant
might encourage early registration. The maternity ward
had only a limited number of beds, and the turnover was
fast, which meant the mothers could rarely stay longer
than 2–3 days after a normal delivery, even if they did
not feel ready to go home. The nurses wanted to check
and teach the mothers about recovery, breast feeding,
and child care, although the mothers might not have
been ready for the information (cf. Dykes, 2005). First-
time immigrant mothers and mothers who delivered
for the first time in Finland, and who had no relatives,
needed assurance that the nurse would assist them if any
problems occurred at home. Finnish first-time moth-
ers have also been reported (Bondas, 2002; Bondas &
Eriksson, 2001) to feel lonely or lose friends because of
childbearing and need help from the nurse to form new
networks.
With respect to the theory of being with child
(Bondas, 2005), there seemed to be no interaction
between immigrant new mothers and Finnish mothers.
The caring communion between the new mother and
the nurse, as well as the family communion between
Immigrant New Mothers in Finnish Maternity Care  Wikberg et al.  95
the new mother and her partner or grandmother, was
incomplete.
Costs saved in maternity care when having a fast
turnover in the hospital and not using interpreters
might be lost when mothers have medical interventions
or complications because of communication problems
or the unnecessary use of emergency services. The
complaints about poor information exchange between
hospital and antenatal clinics could partly be caused by
the laws and acts that safeguard the rights of the patients
when exchanging information between different health
organizations. A Health Care Act (Finlex, 2010) has
since been implemented that should improve exchange
of information.
In spite of the maternity ward’s philosophy that
included family-centered care, no family rooms were
available after delivery. During the study, a stricter rule
about visiting was introduced—only the father and the
siblings could visit—because of influenza epidemics.
Grewal, Bhagat, and Balneaves (2008) have suggested
that family-centered care should incorporate cultural
traditions in a respectful way. Flexible time schedules
at the antenatal clinics and information to fathers about
their rights to attend might increase the immigrant
fathers’ presence. Some nurses seemed to have a preju-
dice toward Finnish fathers marrying foreign women.
A positive attitude toward fathers and their experience
of childbirth and becoming a father might make them
more willing to participate. According to Börjesson,
Paperin, and Lindell (2004), the new mother receives
the most support from the husband and her own
mother. They are not always available and sometimes
prevented from entering the country by immigration
regulations (cf. Ny et al., 2007).
The immigrant new mothers’ initial disappoint-
ments (cf. Upvall, Mohammed, & Dodge, 2009) could
have been avoided if they had received more informa-
tion about the Finnish maternity care organization.
Many of the mothers in this study wanted more ultra-
sound examinations than are offered in maternity care
in Finland. According to Hofmann (2007), technology
such as ultrasound has received new values and uses
than it was originally intended for. Ultrasound in
itself is wanted because it is a sign of progress and
status, and instead of detecting the abnormal, it is
used to calm worried parents that everything looks
normal. The mothers in this study liked to see the
baby and get a picture to keep and show others, but
it also calmed them if they were worried about the
health of the baby.
96  Immigrant New Mothers in Finnish Maternity Care  Wikberg et al.
The immigrant new mothers’ feelings of loneliness
and insecurity might be intensified by the Finnish cul-
tural view of women as independent and the emphasis
on self-care. Many collective cultures have an extended
family concept, where family includes more than the
Finnish core family of an individualistic society (cf.
Banjara, 2011; Hanssen, 2004). Networks or doulas
(Akhavan & Lundgren, 2010) for immigrant mothers,
as well as the extended use of nurses in the antenatal
clinic, who have caring relationships for an extended
time with the immigrant new mothers, might decrease
their vulnerability and loneliness and help the mothers
build a network of friends.
In this study, it seemed as if the newly arrived
mothers were more likely to follow the traditions of
their original culture, whereas the mothers that had
immigrated several years ago had adapted to or accepted
many of the Finnish practices in maternity care. Oppo-
site findings have been described by Brathwaite and
Williams (2004), who studied Chinese immigrants
in Canada, where the newest arrivals were less likely
to follow traditional practices. Acculturation, among
other things, has been used to explain “the healthy
immigrant effect,” which refers to the fact that even
though immigrants are usually healthy upon entering
a country, within 10 years, they have similar health to
the majority population in a country (Higginbottom et
al., 2012). According to Samarasinghe, Fridlund, and
Arvidsson (2010), nurses need to consider the impor-
tance of acculturation and the meaning of family for the
health of the mother to avoid imposing an ethnocentric
view of health, focusing on the physical health of the
mother, which was also found in this study. However,
the acculturation might be unique to the encountering
cultures and the life situation of the individual immi-
grant mother.
In the model for intercultural caring (cf. Wikberg
& Bondas, 2010; Wikberg & Eriksson, 2008; Wikberg
et al., 2012), universal caring, the cultural background,
maternity care context, and unique needs and wishes
of the mothers, as well as the external circumstances in
their life situation, are important for health and well-
being. Caring takes place in the relationship between
the nurse and the mother, and therefore, the relation-
ship is of utmost importance for the experience and
outcome of the childbirth (Hunter et al., 2008). The
cultures of the nurse and the mother are seen as equal,
meaning they are equally valuable and important in the
encounter. Both cultures influence the caring encoun-
ter, which can empower the immigrant new mother.
External circumstances, such as the organization of
maternity care, the availability of interpreters, and
immigrant regulations, might hide some of the car-
ing and disempower the immigrant new mother. The
immigrant new mothers could be compared to the
metaphor of Alice in Wonderland (Wikberg & Bondas,
2010), where they entered a strange land with confus-
ing rules. The caring dimensions—universal, cultural,
contextual, and unique—need to be seen from both the
mother’s perspective and from the nurse’s maternity care
culture perspective. On the one hand, there are nurses
who really want and try to care for the mothers, but
on the other hand, there are outer circumstances that
make it difficult. If caring is not present, the encounter
with the maternity care might cause suffering. The eth-
ics of intercultural caring is to see suffering caused by
cultural differences, cultural incompetence, disempow-
ering relationships, and the prejudice of nurses. The
Finnish maternity care culture influences the mother’s
experience of caring at the same time as it changes with
the encounter with immigrant new mothers. This study
supported that caring promotes health and well-being
and alleviates suffering and that the absence of caring
might cause suffering. It also supported that external
circumstances influence the experience of caring and
therefore, the health and well-being of immigrant new
mothers.
Credibility and Trustworthiness
The focus of the study was caring; however, the par-
ticipants described both caring and noncaring. The
ethnographic observations and field notes together
with interviews brought about a deeper understanding
of the perspectives of the mothers because what the
participants said could also be seen or experienced and
not only verbally expressed (cf. Zhao, Esposito, & Wang,
2010). Observations also showed cultural behavior and
produced new data for the study.
The transcriptions were read in the interview
languages so as not to lose any meaning but were
analyzed in Swedish. The back-translation of the
Finnish and Swedish quotations guaranteed that the
original meaning was preserved. Only minor altera-
tions of the language have been made to make the
quotations more understandable. To ensure trust-
worthiness, the transparency of the study, the setting,
participants, method, and the ethical issues have
been emphasized.

Limitations and Further Research
The participants might have changed their behavior
because an observer was present, which may have
inhibited their answers because the interview was
recorded or because the request for informed consent,
including their signatures, was asked for. A follow-up
interview could have given more data and deepened the
study further. The availability of professional interpret-
ers could have deepened some of the interviews and
enabled additional mothers to participate. On the other
hand, using interpreters involves several layers of inter-
pretation (Brämberg & Dahlberg, 2012), which could
blur understanding. Many non-Western cultures have
an oral narrative tradition, whereas Finnish culture is
heavily based on written and electronic information
besides some practical demonstration. The partici-
pants’ understanding of the concepts of family, health,
and suffering was not studied. Maternity care culture
might be different in other regions of Finland, even
if the national regulations are the same. Traditional
minorities and illegal immigrants, who were not part of
this study, might have a different view about caring in
maternity care.
More extensive studies could be conducted to find
out if a lack of consideration for language or culture or
racism or external circumstances are experienced as
affecting well-being and health from the immigrant new
mothers’ perspectives. How will acculturation change
the experiences of the mothers? Will the next gen-
eration of mothers with a different cultural background
have similar experiences? The experiences of Finnish
mothers who have foreign partners as well as experi-
ences of Finnish women giving birth abroad could
be studied. Would more caring relationships improve
the health outcomes of immigrant mothers and their
babies? More research on caring for immigrant mothers
from the perspective of Finnish nurses and doctors is
needed as well.
Implications
Some implications are suggested about the organiza-
tion, education, laws, and attitudes of nurses (See
Table 2). Patients should be able to expect a maternity
organization that accommodates their need for support
during pregnancy, labor, and the postpartum period,
including professional interpreters, and genuine family-
centered care. The immigrant mother should be able to
Immigrant New Mothers in Finnish Maternity Care  Wikberg et al.  97
expect nurse-initiated discussions about her cultural,
maternity-related, and unique needs and expectations.
Cultural competence, including caring, should be pro-
moted, whereas ethnocentricity, incompetence, racism,
and discrimination should be worked against. Flexibility
and humanity in implementing and interpreting the
laws are needed.
CONCLUSIONS
The mothers’ cultural and unique expectations or
needs were not always recognized, which was per-
ceived as cultural insensitivity; however, when the
cultural background was recognized, it was perceived
as being the expert knowledge of the nurse, and it
empowered the mothers. The nurses’ natural way
of caring in the Finnish maternity care culture was
often unreflective toward the immigrant new moth-
ers’ culture and life situation, which could be seen
as ethnocentric or as an imposition of cultural pain
or causing cultural suffering. General Finnish policy
and politics influenced the desire to have children,
access to and experience of maternity care, and the
loneliness of immigrant new mothers. A vulnerable
life situation increases suffering. Therefore, both pre-
vious (traumatic memories) and present life situa-
tions (insecurity of asylum seekers, resettlement, and
acculturation) need to be considered in nursing care.
The adjustment of maternity care organizations to the
needs of mothers from other cultures might increase
their feeling of well-being, possibly even improve
health outcomes, and save costs in the long term.
The prejudice of nurses as well as an extended under-
standing of the family should be considered to accom-
modate the family of immigrant new mothers to
maternity care. Even though there is some universal
caring, immigrant new mothers are very heterogenic,
having different cultural backgrounds, maternity tra-
ditions, life situations, and different support organiza-
tions and need therefore to be encountered as unique
individuals. To improve general awareness, nurses
and researchers might need to take a more active role
in informing health care politicians, policy makers,
and administrators on the importance of caring, the
life situations of immigrant mothers, and the influ-
ence of external circumstances to alleviate suffering
and promote health and well-being for immigrant
new mothers.
98  Immigrant New Mothers in Finnish Maternity Care  Wikberg et al.

TABLE 2  Implications for Practice

Organization Flexible time schedules at antenatal clinics are needed to facilitate for the fathers’ participation. More
beds are needed in the maternity wards so the mothers can stay longer if they do not feel secure
with baby care and breastfeeding. Alternatively, more intense support through home visits by nurses
and help to build networks are needed. Family rooms in postnatal wards support the participation of
fathers and other family. Continued employment of auxiliary pediatric nurses might be a good and
economic solution to assist mothers who want to stay longer in the hospital or who need more help
at home. Placing mothers in the ward according to language skills instead of nationality or cultural
background could improve the satisfaction of the mother, as well as network building. Continuity of
maternity care during summer holidays needs to be improved. Caring could be included in mater-
nity philosophy on all levels. Encouraging, educating, and employing doulas from the local ethnic
communities, as well as allowing predelivery visits of immigrant new mothers to the delivery ward,
and including discussions about the mother’s needs and cultural expectations could further improve
the childbearing experience.
Education Intercultural caring should be included in the education of all nurses and doctors according to the
recommendations of the Ministry of Education (2006). The education should contain information
about the importance of caring, the connection between caring and the experience of health and
well-being, the influence of previous traumatic experiences and external circumstances on the
nursing care situation and health, as well as an understanding of the total life situation of the im-
migrant. Cultural, contextual, as well as unique caring needs should be considered. The education
should additionally contain information about general theories and concepts as well as specific
cultures and contexts.
Laws Enable the presence of fathers and grandmothers during childbearing by allowing them to enter the
country. Be flexible with the maternity grant if the mother has just arrived, and she has not been able
to attend the antenatal clinic as required. Follow the Act of Patients’ Rights by arranging interpreters
when needed to give information and good quality care. In addition, women without health insur-
ance cards need to receive care and caring during pregnancy and birth.
Attitudes of nurses Continue a friendly attitude toward children and immigrant mothers. Prepare for counteractions toward
the intolerance of immigrants, which can change the positive attitudes the immigrant mothers have of
Finnish society. Nurses need to become aware of their attitude toward fathers and involve them more
in the care. Nurses need to take a more active role in informing politicians, policy makers, and ad-
ministrators of the needs of caring and the life situation of immigrant mothers to safeguard maternity
care resources and changes of restricting rules and policies. Continue the baby-friendly movement by
genuinely supporting the positive attitude toward breastfeeding by immigrant mothers.

REFERENCES Health Sciences, University of Eastern Finland, Kuo-

pio, Finland.

Adjekughele, J. (2003). A reflection on Finnish maternity and
child health clinics from the perspective of mothers
from the African continent. In K. Clarke (Ed.), Welfare
research into marginal communities in Finland: Insider
perspectives on health and social care. Research Reports,
Series A, No. 8 (pp. 31–73). Tampere, Finland: Uni-
versity of Tampere, Department of Social Policy and
Social Work.
Akhavan, S., & Lundgren, I. (2010). Midwives’ experiences
of doula support for immigrant women in Sweden—A
qualitative study. Midwifery, 28, 80–85. http://dx.doi.
org/10.1016/j.midw.2010.11.004
Banjara, T. K. (2011). Perceptions and experiences of mater-
nity care by South Asian immigrant mothers living
in Finland (Unpublished master’s thesis). Faculty of
Beck, C. T. (2006). Pentadic cartography: Mapping birth
trauma narratives. Qualitative Health Research, 16,
453–466. http://dx.doi.org/10.1177/1049732305285968
Beine, K., Fullerton, J., Palinkas, L., & Anders, B. (1995). Con-
ceptions of prenatal care among Somali women in San
Diego. Journal of Nurse-Midwifery, 40, 376–381. http://
dx.doi.org/10.1016/0091-2182(95)00024-E
Berggren, V., Bergström, S., & Edberg, A. K. (2006). Being
different and vulnerable: Experiences of immigrant
African women who have been circumcised and
sought maternity care in Sweden. Journal of Transcul-
tural Nursing, 17, 50–57. http://dx.doi.org/10.1177/
1043659605281981
Bondas, T. (2000). Att vara med barn. En vårdvetenskaplig
studie av kvinnors upplevelser under perinatal tid [To be

with child. A study of women’s lived experience from
a caring science perspective] (Doctoral dissertation).
Åbo Akademi University Press, Turku, Finland.
Bondas, T. (2002). Finnish women’s experiences of antenatal
care. Midwifery, 18, 61–71.
Bondas, T. (2005). To be with child: A heuristic synthesis in
maternal care. In R. Balin (Ed.), Trends in midwifery
research (pp. 119–136). New York, NY: Nova Science.
Bondas, T., & Eriksson, K. (2001). Women’s lived experi-
ences of pregnancy: A tapestry of joy and suffering.
Qualitative Health Research, 11, 824–840. http://dx.doi
.org/10.1177/104973201129119415
Börjesson, B., Paperin, C., & Lindell, M. (2004). Mater-
nal support during the first year of infancy. Jour-
nal of Advanced Nursing, 45, 588–594. http://dx.doi
.org/10.1046/j.1365-2648.2003.02950.x
Brämberg, E. B., & Dahlberg, K. (2012). Interpreters in cross-
cultural interviews: A three-way coconstruction of data.
Qualitative Health Research, 23, 241–247. http://dx.doi
.org/10.1177/1049732312467705
Brämberg, E. B., & Nyström, M. (2010). To be an immigrant
and patient in Sweden: A study with an individualised
perspective. International Journal of Qualitative Stud-
ies on Health and Well-being, 5, 5106. http://dx.doi
.org/10.3402/qhw.v5i3.5106
Brathwaite, A. C., & Williams, C. (2004). Childbirth expe-
riences of professional Chinese Canadian women.
Journal of Obstetric, Gynecologic, and Neonatal
Nursing, 33, 748–755. http://dx.doi.org/10.1177/
0884217504270671
Browne, A., & Fiske, J. A. (2001). First Nations women’s
encounters with mainstream health care services. West-
ern Journal of Nursing Research, 23, 126–147. http://
dx.doi.org/10.1177/019394590102300203
Callister, L. C. (2012). Every mother and child count. Nurs-
ing for Women’s Health, 16, 51–56. http://dx.doi
.org/10.1111/j.1751-486X.2012.01700.x
Callister, L. C., Vehviläinen-Julkunen, K., & Lauri, S. (2001).
Giving birth. Perceptions of Finnish childbearing
women. The American Journal of Maternal Child Nurs-
ing, 26, 28–32.
Carolan, M., & Cassar, L. (2010). Antenatal care perceptions
of pregnant African women attending maternity ser-
vices in Melbourne, Australia. Midwifery, 26, 189–201.
http://dx.doi.org/10.1016/j.midw.2008.03.005
Choté, A., de Groot, C., Bruijnzeels, M., Redekop, K., Jaddoe,
V., Hofman, A., . . . Foets, M. (2011). Ethnic differences
in antenatal care use in a large multi-ethnic urban
population in the Netherlands. Midwifery, 27, 36–41.
http://dx.doi.org/10.1016/j.midw.2009.07.008
Immigrant New Mothers in Finnish Maternity Care  Wikberg et al.  99
Correa-Velez, I., & Ryan, J. (2012). Developing a best
practice model for refugee maternity care. Women
and Birth, 25, 13–22. http://dx.doi.org/10.1016/j.
wombi.2011.01.002
Davies, M., & Bath, P. (2001). The maternity information con-
cerns of Somali women in the United Kingdom. Journal
of Advanced Nursing, 36, 237–245.
Dykes, F. (2005). A critical ethnographic study of encounters
between midwives and breast-feeding women in post-
natal wards in England. Midwifery, 21, 241–252. http://
dx.doi.org/10.1016/j.midw.2004.12.006
Elebro, K., Rööst, M., Moussa, K., Johnsdotter, S., & Essén,
B. (2007). Misclassified maternal deaths among East
African immigrants in Sweden. Reproductive Health
Matters, 15, 153–162. http://dx.doi.org/10.1016/
S0968-8080(07)30322-4
Eliasson, M., Kainz, G., & von Post, I. (2008). Uncaring
midwives. Nursing Ethics, 15, 500–511. http://dx.doi
.org/10.1177/0969733008090521
Eriksson, K. (2002). Caring science in a new key. Nurs-
ing Science Quarterly, 15, 61–65. http://dx.doi
.org/10.1177/089431840201500110
Eriksson, K. (2006). The suffering human being. Chicago, IL:
Nordic Studies Press.
Essén, B., Johnsdotter, S., Hovelius, B., Gudmundsson, S.,
Sjöberg, N. O., Friedman, J., & Östergren, P. O. (2000).
Qualitative study on pregnancy and childbirth experi-
ences in Somalian women resident in Sweden. British
Journal of Obstetrics and Gynaecology, 107, 1507–1512.
http://dx.doi.org/10.1111/j.1471-0528.2000.tb11676.x
Finlex. (1992). Act on the status and rights of patients. Act
number 785. Finnish Ministry of Justice. Retrieved
from http://www.finlex.fi/en/laki/kaannokset/1992/
en19920785.pdf
Finlex. (2010). Health Care Act. Act number 1326. Finnish
Ministry of Justice. Retrieved from http://www.finlex.
fi/en/laki/kaannokset/2010/en20101326.pdf
Forssén, A. (2012). Lifelong significance of disempower-
ing experiences in prenatal and maternity care:
Interviews with elderly Swedish women. ­ Qualitative
Health Research, 22, 1535–1546. http://dx.doi
.org/10:1177/1049732312449212
Geertz, C. (1973). Thick description: Toward an interpre-
tive theory of culture. In The interpretation of cultures:
Selected essays (pp. 3–30). New York, NY: Basic Books.
Retrieved from http://hypergeertz.jku.at/GeertzTexts/
Thick_Description.htm
Gissler, M., Malin, M., & Matveinen, P. (2006). Terveydenhuol-
lon palvelut ja sosiaalihuollon laitospalvelut. [Health
care service and social care institution service.] In:
100  Immigrant New Mothers in Finnish Maternity Care  Wikberg et al.
M. Gissler, M. Malin, P. Matveinen, M. Sarvimäki, &
A. Kangasharju (Eds.), Maahanmuuttajat ja julkiset
palvelut [Immigrants and public service]. (Työpoliit-
tinen tutkimus 296) [Labour political research 296].
(pp. 1–98). Helsinki, Finland: Työministeriö. Retrieved
from: http://www.mol.fi/mol/fi/99_pdf/fi/06_tyominis-
terio/06_julkaisut/06_tutkimus/tpt296.pdf
Grewal, S., Bhagat, R., & Balneaves, L. (2008). Perinatal
beliefs and practices of immigrant Punjabi women
living in Canada. Journal of Obstetric, Gynecologic,
and Neonatal Nursing, 37, 290–300. http://dx.doi
.org/10.1111/j.1552-6909.2008.00234.x
Hallgren, A., Kihlgren, M., & Olsson, P. (2005). Ways of relat-
ing during childbirth: An ethical responsibility and
challenge for midwives. Nursing Ethics, 12, 605–621.
http://dx.doi.org/10.1191/0969733005ne831oa
Hanssen, I. (2004). An intercultural nursing perspective
on autonomy. Nursing Ethics, 11, 28–41. http://dx.doi
.org/10.1191/0969733004ne664oa
Heikkilä, K., & Ekman, S. L. (2000). Health care experiences
and beliefs of elderly Finnish immigrants in Sweden.
Journal of Transcultural Nursing, 11, 281–289. http://
dx.doi.org/10.1177/104365960001100406
Higginbottom, G., Morgan, M., Dassanayake, J., Eyford, H.,
Alexandre, M., Chiu, Y., . . . Kocay, D. (2012). Immi-
grant women’s experiences of maternity-care services in
Canada: A protocol for systematic review using a nar-
rative synthesis. Systematic Reviews, 1, 27. http://dx.doi
.org10.1186/2046-4053-1-27. Retrieved from http://
www.systematicreviewsjournal.com/content/1/1/27
Hill, N., Hunt, E., & Hyrkäs, K. (2012). Somali immigrant
women’s health care experiences and beliefs regard-
ing pregnancy and birth in the United States. Jour-
nal of Transcultural Nursing, 23, 72–81. http://dx.doi
.org/10.1177/1043659611423828
Hoang, H. T., Le, Q., & Kilpatrick, S. (2009). Having a baby in
the new land: A qualitative exploration of the experi-
ences of Asian migrants in rural Tasmania, Australia.
Rural and Remote Health, 9, 1084. Retrieved from http://
www.rrh.org.au/articles/defaultnew.asp?IssueNo=9x
Hofmann, B. (2007). Vi vil jo ha ultalyd! Om teknologiens
verdier [But we want ultrasound! About the values of
technology]. In Å. Slettebø & P. Nortvedt (Eds.), Etikk
for helsefagene [Ethics for the health sciences] (2nd ed.,
pp. 104–123). Oslo, Norway: Gyldendal Akademisk.
Hunter, B., Berg, M., Lundgren, I., Ólafsdóttir, Ó., & Kirkham,
M. (2008). Relationships: The hidden treads in the tap-
estry of maternity care. Midwifery, 24, 132–137. http://
dx.doi.org/10.1016/j.midw.2008.02.003
Johnstone, M. J., & Kanitsaki, O. (2009). The spectrum
of ‘new racism’ and discrimination in hospital con-
texts: A reappraisal. Collegian, 16, 63–69. http://dx.doi
.org/10.1016/j.colegn.2009.03.001
Kela—The Social Insurance Institution of Finland. (2011).
Families. Retrieved from http://www.kela.fi/in/internet/
english.nsf/NET/081101123937EH?OpenDocument
Lamp, J. K. (1998). Generic and professional culture care mean-
ings and practices of Finnish women in birth within
Leininger’s theory of culture care diversity and universal-
ity (Doctoral dissertation). Graduate School of Wayne
State University, Detroit, MI.
Leininger, M. (2006). Culture care diversity and universal-
ity theory and evolution of the ethnonursing method.
In M. Leininger & M. McFarland (Eds.), Culture care
diversity and universality. A worldwide nursing theory.
(2nd ed., pp. 1–41). Sudbury, MA: Jones and Bartlett.
Lindström, U., Lindholm, L., & Zetterlund, J. (2006). Katie
Eriksson: Theory of caritative caring. In A. Marriner
Tomey & M. Alligood (Eds.), Nursing theorists and
their work (6th ed., pp. 191–223). St. Louis, MO: Mosby
Elsevier.
Lundgren, I., Karlsdottir, S., & Bondas, T. (2009). Long-term
memories and experiences of childbirth in a Nordic
context—A secondary analysis. International Journal of
Qualitative Studies on Health and Well-being, 4, 115–128.
http://dx.doi.org/10.1080/17482620802423414
Lyberg, A., Viken, B., Haruma, M., & Severinsson, E.
(2012). Diversity and challenges in the manage-
ment of maternity care for migrant women. Journal
of Nursing Management, 20, 287–295. http://dx.doi
.org/10.1111/j.1365-2834.2011.01364.x
Lyons, S., O’Keeffe, F., Clarke, A., & Staines, A. (2008). Cultural
diversity in Dublin maternity services: The experiences
of maternity service providers when caring for ethnic
minority women. Ethnicity and Health, 13, 261–276.
http://dx.doi.org/10.1080/13557850801903020
Malin, M., & Gissler, M. (2009). Maternal care and birth
outcomes among ethnic minority women in Finland.
BioMed Central Public Health, 9, 84. http://dx.doi
.org/10.1186/1471-2458-9-84
Ministry of Education. (2006). Ammattikorkeakoulusta ter-
veydenhuoltoon [From University of Applied Sciences to
Health care]. Koulutuksesta valmistuvien ammatillinen
osaaminen, keskeiset opinnot ja vähimmäisopintopisteet
[Professional knowledge of the graduated, central studies
and minimum credits]. (Opetusministeriön työryh-
mämuistioita ja selvityksiä 24) [Memos of workgroups
and clarifications of the Ministry of Education 24].
Helsinki, Finland: Opetusministeriö, Koulutus- ja tie-
depolitiikan osasto.
Mulhall, A. (2003). In the field: Notes on observation in qualita-
tive research. Journal of Advanced Nursing, 41, 306–313.
 Immigrant New Mothers in Finnish Maternity Care  Wikberg et al.  101
Murray, L., Windsor, C., Parker, E., & Tewfik, E. (2010). The
experience of African women giving birth in Brisbane,
Australia. Health Care for Women International, 31, 458–
472. http://dx.doi.org/10.1080/07399330903548928
National Advisory Board on Research Ethics. (2002). Good
scientific practice and procedures for handling miscon-
duct and fraud in science. Retrieved from http://www.
tenk.fi/en/good_scientific_practice/Hyva_Tieteel-
linen_ENG.pdf
National Advisory Board on Research Ethics. (2009). Ethical
principles of research in the humanities and social and
behavioural sciences and proposals for ethical review.
Retrieved from http://www.tenk.fi/eettinen_enna-
kkoarviointi/ethicalprinciples.pdf
National Institute for Health and Welfare. (2011a). Perinatal
statistics: Parturients, deliveries and newborns 2010.
Statistical report 27. Retrieved from http://www.stakes.
fi/tilastot/tilastotiedotteet/2011/Tr27_11.pdf
National Institute for Health and Welfare. (2011b). Kuol-
leisuustilastot vuodesta 1950 lähtien [Mortality statis-
tics from 1950]. Retrieved from http://www.stakes.fi/
tilastot/tilastotiedotteet/2011/liitetaulukot/Kuolleisu-
ustilastot_2012.xls
Nikkonen, M., Janhonen, S., & Juntunen, A. (2001). Hoitokult-
tuurin tutkimuksesta: Etnografia hoitotieteellisessä
tutkimuksessa. [From research on nursing culture:
Ethnography in nursing research]. In S. Janhonen &
M. Nikkonen (Eds.), Laadulliset tutkimusmenetelmät
hoitotieteessä [Qualitative methods in nursing science]
(pp. 44–80). Helsinki, Finland: Werner Söderström
Osakeyhtiö.
Ny, P., Plantin, L., Karlsson, E., & Dykes, A. K. (2007).
Middle Eastern mothers in Sweden, their experiences
of the maternal health service and their partner’s
involvement. Reproductive Health, 4, 9. http://dx.doi
.org/10.1186/1742-4755-4-9
O’Mahony, J., & Donnelly, T. (2010). Immigrant and ref-
ugee women’s post-partum depression help-­ seeking
experiences and access to care: A review and analy-
sis of the literature. Journal of Psychiatric and Men-
tal Health Nursing, 17, 917–928. http://dx.doi
.org/10.1111/j.1365-2850.2010.01625.x
Robertson, E. (2003). Aspects of foreign-born women’s health
and childbirth related outcomes. An epidemiological
study of women of childbearing age in Sweden (Doctoral
dissertation). Department of Clinical Sciences, Fam-
ily Medicine, Karolinska Institutet, Stockholm, Swe-
den. Retrieved from http://publications.ki.se/xmlui/
bitstream/handle/10616/39441/thesis.pdf?sequence=1
Roper, J., & Shapira, J. (2000). Ethnography in nursing research.
Thousand Oaks, CA: Sage.
Samarasinghe, K., Fridlund, B., & Arvidsson, B. (2010).
Primary health care nurses’ promotion of invol-
untary migrant families’ health. International
Nursing Review, 57, 224–231. http://dx.doi.
org/10.1111/j.1466-7657.2009.00790.x
Shafiei, T., Small, R., & McLachlan, H. (2012).Women’s
views and experiences of maternity care: A study of
immigrant Afghan women in Melbourne, Australia.
Midwifery, 28, 198–203. http://dx.doi.org/10.1016/j.
midw.2011.02.008
Small, R., Liamputtong Rice, P., Yelland, J., & Lumley, J.
(1999). Mothers in a new country: The role of culture
and communication in Vietnamese, Turkish and Fili-
pino women’s experiences of giving birth in Australia.
Women and Health, 28, 77–101.
Spradley, J. (1979). The ethnographic interview. New York, NY:
Holt, Rinehart and Winston.
Statistics Finland. (2012). Population structure. Retrieved from
http://pxweb2.stat.fi/database/StatFin/vrm/vaerak/
vaerak_en.asp
Tebid, R., Du Plessis, D., Beukes, S., van Niekerk, V., & Jooste,
K. (2011). Implications for nurse managers arising from
immigrant women’s experience of midwifery care in a
hospital. Journal of Nursing Management, 19, 967–975.
http://dx.doi.org/10.1111/j.1365-2834.2011.01310.x
Upvall, M., Mohammed, K., & Dodge, P. (2009). Perspectives
of Somali Bantu refugee women living with circumci-
sion in the United States: A focus group approach. Inter-
national Journal of Nursing Studies, 46, 360–368. http://
dx.doi.org/10.1016/j.ijnurstu.2008.04.009
Vangen, S., Stoltenberg, C., & Stray-Pedersen, B. (1999).
Complaints and complications in pregnancy: A study
of ethnic Norwegian and ethnic Pakistani women
in Oslo. Ethnicity and Health, 4, 19–28. http://dx.doi
.org/10.1080/13557859998155
Wikberg, A., & Bondas, T. (2010). A patient perspective in
research on intercultural caring in maternity care: A
meta-ethnography. International Journal of Qualitative
Studies on Health and Well-being, 5(1), 4648. http://
dx.doi.org/10.3402/qhw.v5i1.4648
Wikberg, A., & Eriksson, K. (2008). Intercultural caring—
An abductive model. Scandinavian Jour-
nal of Caring Science, 22, 485–496. http://dx.doi
.org/10.1111/j.1471-6712.2007.00555.x
Wikberg, A., Eriksson, K., & Bondas, T. (2012). Intercul-
tural caring—An ethnography from the perspective of
immigrant new mothers. Journal of Obstetric, Gyneco-
logic, and Neonatal Nursing, 41, 638–649. http://dx.doi
.org/10.1111/j.1552-6909.2012.01395.x
Zhao, M., Esposito, N., & Wang, K. (2010). Cultural beliefs and
attitudes toward health and health care among Asian-
102  Immigrant New Mothers in Finnish Maternity Care  Wikberg et al.

born women in the United States. Journal of Obstetric,

Gynecologic, and Neonatal Nursing, 39, 370–385. http://
dx.doi.org/10.1111/j.1552-6909.2010.01151.x
Correspondence regarding this article should be directed to
Anita Wikberg, MNSc, RN, RM, PhD student, Åbo Akademi
University, Department of Caring Science, PB 311, 65101
Vaasa, Finland. E-mail: anita.wikberg@novia.fi
Anita Wikberg, MNSc, RN, RM, PhD student, Åbo Akademi
University, Department of Caring Science, Vaasa, Finland.
Katie Eriksson, PhD, RN, Åbo Akademi University, Depart-
ment of Caring Science, Vaasa, Finland.
Terese Bondas, PhD, RN, PHN, University of Nordland, Fac-
ulty of Professional Studies, Bodø, Norway.
Experiences of Women Planning a
Home Birth Who Require Intrapartum
Transfer to Hospital: A Metasynthesis
of the Qualitative Literature
Deborah Fox, Athena Sheehan, and Caroline Homer

Recent evidence supports the safety of planned home birth for low-risk women when professional
midwifery care and adequate collaborative arrangements for referral and transfer are in place. The
purpose of this article is to synthesize the qualitative literature on the experiences of women planning
a home birth, who are subsequently transferred from home to hospital. A metasynthesis approach
was selected because it aims to create a rich understanding of women’s experiences of transfer by syn-
thesizing and interpreting qualitative data. Three categories were synthesized: “communication, con-
nection, and continuity,” “making the transition,” and “making sense of events.” Quality and clarity
of communication, feeling connected to the backup hospital, and continuity of midwifery carer helps
make the transfer process as seamless as possible for women. Arriving at the hospital is a time of vul-
nerability and fear, and retaining the care of a known midwife is reassuring. New caregivers must also
be sensitive to ­women’s need to be reassured and accepted. The reasons for transfer need to be clearly
communicated both at the time of transfer and in more detail during the postpartum period. Women
need to talk through their experience and to acknowledge their feelings of disappointment in order to
move forward in the next phase of their lives. Continuity of carer enables this to be done by a known
caregiver in a sensitive and individualized manner. Further qualitative research to examine home birth
transfer issues, specifically in the Australian context, is currently being planned as part of the Birthplace
in ­Australia project.
Keywords: midwifery; home birth; transfer of care; women’s experiences; metasynthesis

INTRODUCTION birth centers, or in an obstetric unit. For primiparous

Recent evidence supports the safety of planned home
birth for low-risk women when professional midwifery
care and adequate collaborative arrangements for refer-
ral and transfer are in place (Brocklehurst et al., 2012;
Catling-Paull, Coddington, Foureur, & Homer, 2013; de
Jonge et al., 2013; de Jonge et al., 2009). Despite the low
rates of home birth in many developed countries, there
remains a demand for home birth services (Catling-
Paull, Foureur, & Homer, 2012). The recent Birthplace in
­England study (Brocklehurst et al., 2012) demonstrated
no difference in adverse perinatal outcomes for low-risk
multiparous women who planned a birth at home, in
women, there was again no difference when comparing
adverse perinatal outcomes with birth centers or obstetric
units; however, an elevated risk of poor perinatal out-
comes was identified for those primiparous women who
had planned a home birth. Brocklehurst et al. (2012) and
other studies demonstrate a trend for larger proportions
of primiparous women to be transferred than multiparous
women (Blix, Huitfeldt, Øian, Straume, & Kumle, 2012;
Brocklehurst et al., 2012; Johnson & Daviss, 2005; Tyson,
1991; ­Wiegers, van der Zee, & Keirse, 1998). Available
data shows a four to five-fold increase in transfers for
women having their first baby when compared with
women who have given birth before (Table 1).

INTERNATIONAL JOURNAL OF CHILDBIRTH Volume 4, Issue 2, 2014

© 2014 Springer Publishing Company, LLC www.springerpub.com
http://dx.doi.org/10.1891/2156-5287.4.2.103 103
104  Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital  Fox et al.

TABLE 1  Findings of Quantitative Papers Examining Transfer Rates

PRIMIPAROUS MULTIPAROUS
WOMEN WOMEN
AUTHOR, DATE, COUNTRY TOTAL TRANSFER RATES TRANSFERRED TRANSFERRED URGENT TRANSFERS

Amelink-Verburg et al., 2008, 29.3% transfer rate — — —

The Netherlands
Anderson & Murphy, 1995, 9.8% transfer rate (8% in — — 1 in 1,000
United States labor, 0.8% postpartum,
1% neonatal)
Blix et al., 2012, Norway 12.1% transfer rate; 31.7% 6.3% Primiparous women: 1.4% of
transfers occurred during all planned home births
intrapartum period or Multiparous women: 0.9% of
within 5 days after birth. all planned home births
Brocklehurst et al., 2012, 21% transfer rate 45% 12% —
England
Catling-Paull, Dahlen, & Excluded; sample , 20 — — —
Homer, 2011, Australia
Cheyney, 2011, United States 12% transfer rate — — —
Creasy, 1997, England Excluded; sample , 20 — — —
Dahlen, Barclay, & Homer, Excluded; sample , 20 — — —
2010, Australia
Davies, 1997, England 14% uneventful transfers — — None
Durand, 1992, United States 11.9% transfer rate — — —
Janssen et al., 2002, Canada 16.5% during labor — — 3.6% of all planned
(before birth) home births
Janssen et al., 2003, Canada 23.1% transfer rate — — 3.4% of all planned home
births
Johnson & Daviss, 2005, 12.1% transfer rate 25.1% 6.3% Primiparous women: 5.1%
United States and Canada of all planned home births
Multiparous women: 2.6%
of all planned home births
Lindgren et al., 2008, Sweden 12.5% transfer rate — — —
Lindgren, Radestad, & 14.15% transfer rate — — —
­Hildingsson, 2011, Sweden
Murphy & Fullerton, 1998, 10.2% transfer rate: 8.3% 27% 5.7% —
United States in labor, 0.8% PN, 1.1%
neonatal
Tyson, 1991, Canada 16.5% transfer rate 40% 8% —
­(intrapartum or to 4 days
postpartum)
Wiegers et al., 1998, — 40.1% 11.6% —
The Netherlands

Note. Empty cells denote no data available.

Women’s approaches to making decisions about
where to give birth are complex, multifaceted, and
derived from manifold formal and informal sources. It is
clear from the literature, however, that choice and con-
trol is important to women in childbirth (Creasy, 1997;
Janssen, Carty, & Reime, 2006; Vedam, Goff, & Marnin,
2007) and that social and familial reasons are significant
in most women’s choices to give birth at home (Bailes &
Jackson, 2000). Women choosing home birth may value
alternative forms of knowledge and undergo a pro-
cess of challenging hegemonic biomedical paradigms
(Cheyney, 2008), which are widely accepted in society
and commonly exploited in the media. Despite the fact
that hospitals may provide the technological means to
monitor and treat problems in childbirth, awareness
of this is not reassuring to some women. Such women
value the natural processes of their bodies more highly
than scientific and technocratic approaches to birth,
choosing to birth in what they perceive as the safety of
their own homes (Davis-Floyd & Sargent, 1997).
 Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital  Fox et al.  105
Quantitative studies examining transfer rates for
women planning home birth highlight several reasons
for transfer. Most transfers are reported to occur for
nonurgent indications, such as delayed progress in labor
(Amelink-Verburg et al., 2008; Anderson & Murphy,
1995; Davies, Hey, Reid, & Young, 1996; Johnson &
Daviss, 2005; Lindgren, Hildingsson, Christensson, &
Rådestad, 2008; Murphy, 1998), the woman’s request
for pharmacological pain management (Amelink-Ver-
burg et al., 2008; Johnson & Daviss, 2005), or the
­unavailability of her midwife (Lindgren et al., 2008).
Small numbers of women (Amelink-Verburg et al.,
2008; Anderson & Murphy, 1995; Johnson & Daviss,
2005) are transferred because of potentially life-threat-
ening emergencies such as postpartum hemorrhage
(Amelink-Verburg et al., 2008; Anderson & Murphy,
1995; Davies et al., 1996; Durand, 1992; Johnson &
Daviss, 2005; Lindgren et al., 2008; Tyson, 1991) or neo-
natal respiratory distress (Amelink-Verburg et al., 2008;
Anderson & Murphy, 1995; Durand, 1992).
Some women find transfer distressing, whereas
others do not. For example, Wiegers et al. (1998) found
that women who were transferred from planned home
birth to hospital in The Netherlands were as positive as
women who had planned a birth in hospital regarding
their birth experience, their midwife, and the 10 days
postnatal period. However, these findings are in contrast
to those reported by others who have found that trans-
ferred women were less satisfied with their experience.
Lindgren, Rådestad, and Hildingsson (2011) identified
that women who were transferred from planned home
birth to hospital in Sweden were less satisfied than those
who gave birth at home. Similarly, Christiaens, Gouwy,
and Bracke (2007) found that transferred women in
­Belgium and The Netherlands were less satisfied than
those who had planned a hospital birth. This study
included women who planned a home birth at or after
30 weeks’ gestation. No difference was found in satisfac-
tion levels between the women transferred in pregnancy
or women transferred during labor. Most of the trans-
ferred women felt they had made an appropriate choice
about place of birth, but fewer were sure they would
choose home birth again next time. Communication
issues and organizational factors (such as the inability
of the home birth midwife to remain as caregiver in
hospital) were the main contributing reasons for their
dissatisfaction.
In many western countries, women will continue
to choose to plan a home birth despite the challenges
involved. Some of them, and/or their babies, will require
transfer to hospital during labor or soon after birth.
Although guidelines exist for the processes of transfer,
we do not fully understand how women experience this
emotionally and psychologically. Therefore, the aim of
this metasynthesis is to review and synthesize, from the
current literature, the views and experiences of women
in developed countries who have planned a home birth
and subsequently been transferred to hospital during
the intrapartum or early postnatal periods.
METHODS
Design
A metasynthesis approach to the qualitative literature on
the views and experiences of women planning a home
birth, who are subsequently transferred from home to
hospital during labor or in the early postnatal period, was
undertaken. This approach was selected because it aims
to create a rich understanding of women’s experiences of
transfer by analyzing and synthesizing qualitative data.
A metasynthesis attempts to explore phenomena
related to a specific research question to illuminate and
enrich understanding of the chosen phenomenon. More
than a summary of available evidence, it seeks to analyze
existing research in a way that enables new insights, syn-
thesizing between the studies, determining comparisons
and contrasts between them, and identifying relation-
ships and refutations which may be either apparent
or implied. This results in a holistic analysis (Thorne,
Jensen, Kearney, Noblit, & Sandelowski, 2004; Walsh &
Downe, 2005) that is derived from an interpretive para-
digm (Noblit & Hare, 1988). The aim of a metasynthesis
is to develop knowledge in and increase understanding
of a phenomenon of interest (Thorne et al., 2004).
Various approaches to metasynthesis are seen in the
literature (Thorne et al., 2004). Most are informed by the
metaethnographic approach of Noblit and Hare (1988),
considered a seminal work on the method (Thorne
et al., 2004; Walsh & Downe, 2005). Noblit reminds
us that qualitative research is the “. .  . juxtaposition of
the author’s perspective with the perspectives of those
studied” (Thorne et al., 2004, p. 1347). The synthesis
of qualitative research adds a further layer, that of the
interpretation of the synthesizer, who seeks to relate
ordinary concepts from the data to existing discourse
(Thorne et al., 2004).
The structure of this metasynthesis has been
influenced by the approaches of Schmied, Beake, Shee-
han, McCourt, and Dykes (2011); Walsh and Downe
(2005); and Noblit and Hare (1988). Beginning with
106  Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital  Fox et al.
a focused literature search, it then combines findings
from studies that have employed different methodolo-
gies. The original analyses and the authors’ interpreta-
tions contained within the studies, and the relationships
between the studies are used to create new interpreta-
tions. These interpretations are further related to con-
temporary discourse, striving to make the result richer
than the sum of its parts (Thorne et al., 2004; Walsh &
Downe, 2005).
Definitions
For the purposes of this study, planned home birth is
defined as when the planned place of birth at the onset
of labor is the woman’s home, with care from a private
or publicly funded registered midwife. It does not mean
a birth at home unattended by a professional midwife
or a birth before planned arrival to hospital. Transfer is
defined as the transport of a woman who has planned
a home birth, and/or her baby, from home for referral
to an obstetric hospital. This may have occurred after
the onset of labor or within several days after birth.
The transfer may occur because of complications or
risk factors emerging during the labor or immedi-
ate postpartum period, and/or the woman may have
requested a transfer because of social reasons or the
desire for pharmacological pain management. This
study does not include women for whom consultation
with a medical practitioner is sought on the telephone
but subsequently remain at home for birth and the early
postpartum period.
Inclusion and Exclusion Criteria
Qualitative studies or only the qualitative section of
mixed method studies that explored the views and expe-
riences of primiparous and multiparous women plan-
ning a home birth, who are subsequently transferred to
hospital during labor or in the early postnatal period,
were included. Literature on free birthing (Dahlen,
­Jackson, & Stevens, 2011) and home births in developing
countries (Ghazi Tabatabaie, Moudi, & Vedadhir, 2012;
Radoff, Levi, & Thompson, 2012) were excluded because
these bring unique and complex issues that are beyond
our primary aim. Also excluded was literature about
women who, at the onset of labor, plan to give birth in
a hospital but unexpectedly gave birth before reaching
the hospital. In addition, search terms embryo, in vitro
fertilization (IVF), and blastocyst were specific keyword
exclusions. This was decided after an initial search which
drew hundreds of hits related to assisted reproduction.
Search Strategy
For the purposes of a larger PhD study, a systematic
search was undertaken for all literature pertaining to
home birth transfer using the following databases:
Academic Search Complete and CINAHL (Ebsco),
Informit, Cochrane Library (Wiley), Intermid, Mater-
nity and Infant Care, Medline (Ovid), Pubmed, Scopus,
ScienceDirect (Elsevier), ANL Trove (theses), and Pro-
Quest Dissertations and Theses. Search terms included
homebirth OR home birth AND transfer. These broad
search terms were used to encompass the wider scope
of the aforementioned PhD project. Only research
published since 1990 in English was sought because
home birth practice has undergone many changes over
the past 20 years in many countries because of political
issues and midwives’ access to indemnity insurance.
The search attracted 1,520 hits; 333 relevant titles
were chosen for abstract review and following abstract
review, 196 abstracts remained. The full texts of those
papers were sought and reviewed for relevance. After
full text review, 18 papers relating to intrapartum or
early postpartum transfer remained. Of these 18 papers,
14 were quantitative and 4 were qualitative studies. All
the qualitative studies specifically addressed women’s
views and experiences of intrapartum or early postnatal
transfer during a planned home birth (Catling-Paull
et al., 2011; Creasy, 1997; Dahlen et al., 2010; Lindgren
et al., 2011). A further paper was later added which
was published just after the search, which included a
section on the experiences of two transferred women
(McCourt, Rayment, Rance, & Sandall, 2012). Quality
appraisal of these five papers was undertaken using the
Critical Appraisal Skills Programme (2010) “Qualitative
Research checklist.” Five papers that included data from
89 women remained after quality appraisal (Figure 1).
Analysis
The seven-step process of metaethnography proposed
by Noblit and Hare (1988) was used as a basis for this
analysis. The seven steps are illustrated in Figure 2, and
details of the steps as they applied in this study appear
in the following text. Three categories were synthesized:
“communication, connection, and continuity,” “­ making
the transition,” and “making sense of events.” Each
 Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital  Fox et al.  107

Literature search was undertaken, using search terms homebirth OR home birth
AND transfer NOT IVF NOT embryo NOT blastocyst. Articles sought are in
English, published since 1990. Databases searched: Academic Search Complete,
CINAHL, Informit, Cochrane Library, Intermid, Maternity and Infant Care,
Medline (Ovid), Pubmed, Scopus, ScienceDirect, ANL Trove (theses), and
ProQuest Dissertations and Theses.

There were 1,520 hits. There were 333 titles identified as relevant, abstracts
of which were reviewed. Abstracts from studies on home birth in developing
countries were excluded. Literature search was undertaken, and studies on free
birth and unplanned home birth were excluded at this stage.

There were 196 papers that remained; full texts were reviewed. A filter was
applied related to intrapartum or early postpartum transfer to hospital after
planned home birth.

There were 18 papers that remained and were again reviewed. Of these 18
papers, 14 were quantitative and 4 were qualitative studies. All the qualitative
studies specifically addressed women’s views and experiences of intrapartum or
early postnatal transfer during a planned home birth. One additional paper was
later added, which had a section on two women’s experiences of transfer.

There were five papers that remained. Quality appraisal was undertaken using
the Critical Appraisal Skills Programme checklist for appraisal of qualitative
research.

There were five papers that remained for inclusion in the metasynthesis. These
five papers included data from 89 women.

FIGURE 1  Selection process of papers for inclusion in metasynthesis.

108  Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital  Fox et al.

As described in the search strategy, qualitative studies

1.  Identification of topic of interest
2.  Deciding what is relevant to that interest
3.  Reading and repeated reading, noting themes and
concepts inherent in the text
4.  Determining relationships between the studies;
discerning similarities, connections, and contrasts
5.  Translation of the studies into each other
6.  Synthesizing the translations
7.  Expressing the synthesis
FIGURE 2  Seven-step process of metaethnography
(Noblit & Hare, 1988).
c­ ategory was identified in at least two of the papers syn-
thesized (Table 2).
1. Identification of topic of interest
From background reading during the initial literature
search on transfers from planned home birth, it was
identified that synthesizing the views and experiences
of women would be a prudent starting point for under-
standing the issues surrounding the processes of transfer.
2. Deciding what is relevant to that interest
The subject matter to be analyzed in the metasynthesis
was particularly pertaining to the following:
a. Women’s views and experiences (not caregivers’ or
partners’)
b. Intrapartum or early postpartum transfer (not ante-
natal transfer)
c. Qualitatively analyzed empirical studies
that specifically addressed women’s views and experi-
ences of intrapartum or early postpartum transfer
were drawn from the larger search. Mixed method
studies that included a qualitative section were also
useful.
3. Reading and repeated reading, noting themes and
concepts inherent in the text
Ideas started to form about how the studies related by
reading and rereading the studies. Copious pencilled
notes were made on a hard copy of each paper, about
the themes and concepts emerging from each individual
paper.
4. Determining relationships between the studies;
­discerning similarities, connections, and contrasts
From notes on the themes and concepts of each study,
ideas began to formulate about which studies were
saying similar things (e.g., women felt they were met
with negative attitudes upon arrival at hospital), which
studies were saying things which were connected (e.g.,
the different ways in which the benefits of continuity
of midwifery carer emerged from the data), and which
studies found contrasting things (e.g., in some studies,
the home birth midwife was not able to continue caring
for the women in hospital, and in other studies, this was
expected). A table was constructed to reflect the themes
and concepts and the related quotations from women
(raw data) representing this (Table 3). A table describ-
ing the main elements of each study was also formulated
(Table 4).

TABLE 2  Themes and Categories Identified and Related Synthesis Statements

THEMES SYNTHESIZED CATEGORIES SYNTHESIS STATEMENTS

Communication of information Communication, Quality and clarity of communication, feeling connected to the
(antenatal) ­connection, and backup hospital, and continuity of caregiver helps make the
Connectedness with a hospital ­continuity transfer process as seamless as possible for women.
Continuity

Hostile behaviors Making the transition Arriving at the hospital is a time of vulnerability and fear for
Negative attitudes women, and retaining the care of a known midwife is reassur-
ing. New caregivers must also be sensitive to women’s need to
be reassured and accepted.

Understanding why transfer
occurred (intrapartum)
Acknowledging feelings of
disappointment
Moving forward
Making sense of events
The reasons for transfer need to be clearly communicated at
the time of transfer. Women also welcome the opportunity to
understand the circumstances in more detail during the post-
partum period. Women need to talk through their experience
and to acknowledge their feelings of disappointment to move
forward in the next phase of their lives. Continuity of carer
enables this to be done by a known caregiver in a sensitive
and individualized manner.
 Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital  Fox et al.  109
TABLE 3 Synthesized Categories, Themes, and Related Quotations From the Data
COMMUNICATION,
­CONNECTION, AND ­CONTINUITY
Communication of information
Connectedness with a hospital
Continuity
MAKING THE TRANSITION
Hostile behaviors
Negative attitudes
MAKING SENSE OF EVENTS
Understanding why transfer
­occurred
Acknowledging feelings of
­disappointment
Moving forward
RELATED QUOTATIONS
“Originally when I asked for a home delivery and talked to the GP about it, he was sort
of fairly honest in explaining . . . because it was a first birth that there was a reasonable
chance that I’d end up in hospital” (Creasy, 1997, p. 35).
“I needed to know absolutely everything about how it [publicly funded home birth] worked”
(Catling-Paull et al., 2011, p. 125).
“I don’t like the polarization [sic]; being at home or at the hospital. More communication
would have made it easier for everyone involved” (Lindgren et al., 2011, p. 103).
“. . . knowing that if I didn’t want to go ahead with it then I could always back out and still go
to the hospital. I was fine, I was very relaxed about it” (Catling-Paull et al., 2011, p. 125).
“Some of my family thought it was really nice and really good that I was already a patient
there and transfer would be really smooth. If I had to transfer it would be ok” (Catling-
Paull et al., 2011, p. 125).
“I just like the idea of the backup there, the continuity. I just like the fact that I go to hospital
for my appointments and the hospital is the one looking after me” (Catling-Paull et al.,
2011, p. 125).
“. . . I just wished that my homebirth midwife had been allowed to stay with me” (Lindgren
et al., 2011, p. 103).
“. . . [Midwife, C] always kept me very focused and in control of the situation, we were . . .
worked very well together as a team” (McCourt et al., 2012, p. 8).
“When we came to hospital we felt like aliens, the atmosphere was hostile and I was scared”
(Lindgren et al., 2011, p. 103).
“The doctor looked me in the eyes and said ‘What would have happened if you hadn’t had
the option of coming here when things went wrong?’” (Lindgren et al., 2011, p. 103).
“It was hard to meet people at the hospital, and being confronted with their negative at-
titudes towards homebirths” (Lindgren et al., 2011, p. 103).
“When we came to the hospital I was exhausted and needed to rest but everyone was so up-
set about my homebirth that I didn’t get a chance to sleep” (Lindgren et al., 2011, p. 103).
“In the postnatal ward we met a midwife who had given birth at home herself, and that was
the first time at the hospital I felt that someone had understood me” (Lindgren et al., 2011,
p. 103).
“The waters broke, and . . . she very calmly just said, ‘Right, the baby has poo-ed inside you,
it’s not a big deal, it’s fine. All we have to do now is call an ambulance,’ So I said, ‘OK,
that’s fine, not a problem’” (McCourt et al., 2012, p. 8).
“The placenta was fixed to the womb, so it couldn’t have come away anyway . . . I did the
important bit myself” (Creasy, 1997, p. 36).
“I felt like I wasn’t good enough and I felt disappointed that my body didn’t do what it was sup-
posed to do” (Lindgren et al., 2011, p. 103).
“I think there’s disappointment or a sense of loss too. Part of me feeling disappointed in my
body . . . Loss of not doing it as I thought I could do it” (Dahlen et al., 2010, p. 1982).
“Giving birth at home was a dream for me. I thought of it as the best start for the baby, so it was
disappointing having to finish the birth at the hospital” (Lindgren et al., 2011, p. 103).
“For eight weeks I did not embrace motherhood . . . I wouldn’t completely let go of my old
life without a baby and not being a mother” (Dahlen et al., 2010 p. 1982).
“I was just busting because I couldn’t talk enough about this . . . I got sick of talking about it
too, but it was unresolved” (Dahlen et al., 2010, p. 1981).
“They would say oh! You’ve got to get on with it. And it was like I don’t need to hear that. I’m
going to get on with it but I’d like to also say it’s not that easy” (Dahlen et al., 2010, p. 1982).
“This time I needed some help but next time I’ll do it at home all the way!” (Lindgren et al.,
2011, p. 103).
“I still strongly think that home is the place to be, yes I still will definitely plan another
homebirth” (Catling-Paull et al., 2011, p. 126).
 TABLE 4  Characteristics of Five Included Studies
AUTHOR, NUMBERS OF ­WOMEN
DATE, PROVIDING RAW
COUNTRY SCOPE AND PURPOSE DESIGN, METHODS SAMPLING, PARTICIPANTS ANALYTIC STRATEGY DATA (89 IN TOTAL)

Dahlen To explore first-time Qualitative, grounded theory Purposeful and theoretical sampling; Grounded theory There was one woman
et al., 2010, mothers’ birth design; in-depth interviews 19 primiparous women, 7 planned interviewed.
Australia ­experiences 6–26 weeks after birth, lasting home births, 1 transferred from
between 20 min and 3 hrs planned home birth to a hospital,
forceps birth
Catling-Paull To explore multiparous Interpretivist; semistructured There were 10 multiparous women, Thematic analysis, There were three
et al., 2011, women’s choices and interviews lasting 1 hr, using all English speaking—3 were trans- constant comparative women interviewed.
Australia experiences of pub- open-ended questions, in their ferred to hospital during intrapartum method of analysis,
licly funded home homes, 6–26 weeks postpartum: ­period. Participants de-identified dur- categories formed
birth Interviews were audio taped. ing transcription from audio tapes.
Creasy, 1997, To explore women’s Mixed method; during a 6-month The qualitative part of the study em- Taped interviews were There were two
England experience of transfer period, 122 women booked ployed purposive sampling. There were transcribed and ana- women interviewed.
from community care for community care (GP unit 14 women who had been transferred lyzed according to
to consultant obstet- or home birth) were followed to consultant care in late pregnancy or grounded theory.
ric care in Sheffield, prospectively. Consent was labor who were invited to participate
England obtained at 32 weeks from in a semistructured interview lasting 30
112 women. Questionnaires min. There were 12 who agreed. There
were sent during antenatal and were 10 who had planned to birth
postnatal periods. Women who in GP unit; 2 planned home births
were transferred were invited for (1 was transferred in labor for failure
semistructured interviews lasting to progress and had a ventouse, 1 was
30 min. The average timing of transferred postnatally for removal of
interview was 30 days postnatal. retained placenta).
Lindgren To compare the experi- Positivist; quantitative data collec- There were 674 women planning a Mixed method analysis: There were 81 women
et al., 2011, ences of women tion, mixed method analysis home birth between 1998 and 2005 quantitative SPSS who responded to
­Sweden planning a home who were invited to participate. and qualitative con- open-ended survey
birth who were Each of the 671 women who agreed tent analysis questions.
transferred and those received one questionnaire. There
110  Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital  Fox et al.

who completed birth were 95 who were transferred. There

at home
McCourt et To explore organiza-
al., 2012, tional and profession-
United al issues impacting
Kingdom on safety and quality
of care in four differ-
ent birth settings in
the United Kingdom
were 81 women who responded to
open-ended survey questions about
their experience of transfer.
Qualitative; ethnographic case There were 156 interviews with women Case study method using There were two
studies and partners, care providers, and interpretive systems women interviewed.
stakeholders. There were 50 prac- approach: Thematic
tice observations and review of and framework analy-
200 documents. sis identified five ar-
eas. NVivo8 was used
to catalogue data.

Note. GP 5 general practitioner; SPSS 5 Statistical Package for Social Sciences.

 Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital  Fox et al.  111
5. Translation of the studies into each other
This stage looked for more nuanced connections
between the raw data from individual studies; what
the authors’ interpretations of the data were offering;
and how different authors’ interpretations were similar,
connected, or contrasting. One example of this was
consideration of the contexts of the five papers and
the focus each author placed on their interpretation.
Despite the studies possessing different foci, emanating
from different countries and cultural contexts (United
Kingdom, Sweden, Australia), and different groups
of women (primiparous women, multiparous women,
women in private and publicly funded models of care), it
was possible to draw similarities and contrasts between
the papers. The identification of these similarities and
contrasts enabled connections to be made and draft
categories to be developed. Each category identified
emerged from in two or more of the papers examined,
from quotations of the women (the raw data), and/or
interpretations of the individual authors.
6. Synthesizing the translations
A more in-depth synthesis, this phase was a final fer-
mentation process of “connecting the dots.” Consensus
(or otherwise) with the authors’ interpretations of their
data, adding further layers of interpretation from the
data and adding further layers of synthesis to the authors’
interpretations of their data, was achieved. In addition,
it was examined whether one author’s interpretation
may have illuminated the interpretation of another. An
example of this is that issues around continuity of care
emanated from all the papers as a determinant of the
quality of women’s experiences of transfer. This mani-
fested in various ways, but it was possible to contemplate
how the presence or absence of continuity of carer could
influence a woman’s experience during transfer.
7. Expressing the synthesis
Qualitative research may be expressed in a variety of
ways for a range of audiences (Noblit & Hare, 1988).
In this case, the expression of the synthesis is in a writ-
ten form, specifically aimed at a professional journal
audience.
FINDINGS
Of the papers, two used grounded theory (Creasy,
1997; Dahlen et al., 2010), two used thematic analysis
(Catling-Paull et al., 2011; Lindgren et al., 2011), and
one was an ethnographic case study (McCourt et al.,
2012). Two papers were from Australia (Catling-Paull et
al., 2011; Dahlen et al., 2010), one from Sweden (Lind-
gren et al., 2011), and two from the United Kingdom
(Creasy, 1997; McCourt et al., 2012).
Communication, Connection, and Continuity
Women felt reassured during the antenatal period when
they received information about the likelihood and
processes of potential transfer. Feeling connected to a
hospital during pregnancy helped women feel prepared
because they had some knowledge of their destination
if transfer were to occur. This category encompasses the
themes “communication of information,” “connected-
ness with a hospital,” and “continuity.”
Communication of Information
Communication of information by caregivers during
the antenatal period was an important component of
feeling prepared for home birth. Women and fami-
lies appreciated when caregivers encouraged them to
remain open-minded and flexible in their approach to
unexpected outcomes.
Originally when I asked for a home delivery and
talked to the GP about it, he was sort of fairly
honest in explaining . . . because it was a first
birth that there was a reasonable chance that I’d
end up in hospital (Creasy, 1997, p. 35).
Women wanted honest and open information on
the reality and likelihood of transfer, the practical mech-
anisms of transfer, the role of the midwife after transfer,
and the potential interventions which may occur in
hospital. Women provided with such information were
more understanding and accepting of events in hospital
when transfer occurred. Data from the papers high-
lighted this, for example,
I needed to know absolutely everything about
how it [publicly funded home birth] worked
(Catling-Paull et al., 2011, p. 125).
Women also conveyed that the style of the care in
hospital felt different from that received in their home.
One woman felt that better communication may have
ameliorated this by saying,
112  Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital  Fox et al.

for the woman in hospital, this was seen as a negative

I don’t like the polarization; being at home or at (Lindgren et al., 2011):
the hospital. More communication would have
made it easier for everyone involved (­Lindgren et
al., 2011, p. 103). . . . I just wished that my homebirth midwife had
been allowed to stay with me (Lindgren et al.,
2011, p. 103).
Connectedness With a Hospital
Belonging to a publicly funded home birth program
Known caregivers provided reassurance by being
promoted feelings of connectedness with the hospital,
able to communicate in a way that was appropriate to
although there was only one study exploring this specifi-
the individual woman. Explanations which were tai-
cally. Confidence in the hospital as backup was evident
lored to a woman’s individual needs and to her state of
for one woman because she felt she already belonged at
mind and body at the time were more helpful. Women
the hospital when she went there for antenatal appoint-
were more trusting of information given by a caregiver
ments, as highlighted here:
with whom they had a rapport:

I just like the idea of the backup there, the conti-

nuity. I just like the fact that I go to hospital for . . . [Midwife, C] always kept me very focused
my appointments and the hospital is the one look- and in control of the situation, we were . . .
ing after me (Catling-Paull et al., 2011, p. 125). worked very well together as a team (McCourt
et al., 2012, p. 8).

Another woman in the publicly funded home

birth program had expressed (during her antenatal Making the Transition
period) that if she had to transfer, she felt she would be
all right. Her family was also reassured by the connect- The phase of making the transition from home to hos-
edness with the hospital, as in this quote: pital was often made more difficult for women because
of hostile behaviors and negative attitudes displayed by
hospital staff. These themes are reflected here.
Some of my family thought it was really nice and
really good that I was already a patient there and
transfer would be really smooth. If I had to transfer Hostile Behaviors
it would be ok (Catling-Paull et al., 2011, p. 125). Hostile behaviors displayed at the hospital added to
women’s feelings of vulnerability and fear upon arrival.
There were several quotes conveying this:
Flexibility was provided by a sense of belonging to
the hospital and the ability to change place of birth plans
at any time if necessary or desired: When we came to hospital we felt like aliens, the
atmosphere was hostile and I was scared (Lind-
. . . knowing that if I didn’t want to go ahead gren et al., 2011, p. 103).
with it then I could always back out and still go
to the hospital. I was fine, I was very relaxed
about it (Catling-Paull et al., 2011, p. 125).
The doctor looked me in the eyes and said “What
would have happened if you hadn’t had the
option of coming here when things went wrong?”
Continuity
(Lindgren et al., 2011, p. 103).
One of the reasons home birth was chosen by women
in the studies was because of the continuity of care-
giver that is integral to the model of care. Continuity
or lack thereof remained an important determinant . . . I wish they had been more accommodating
in coming to terms with being transferred. When the (Lindgren et al., 2011, p. 103).
home birth midwife was not able to continue caring
 Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital  Fox et al.  113
Negative Attitudes
Negative attitudes displayed by hospital staff about home
birth caused one family to feel marginalized in the hos-
pital setting, with two women saying,
It was hard to meet people at the hospital, and
being confronted with their negative attitudes
towards homebirths (Lindgren et al., 2011, p. 103).
When we came to the hospital I was exhausted
and needed to rest but everyone was so upset
about my homebirth that I didn’t get a chance to
sleep (Lindgren et al., 2011, p. 103).
On the other hand, one woman met a midwife on
the hospital postnatal ward who had herself had a home
birth. This appeared to reduce her feelings of alienation.
She said,
In the postnatal ward we met a midwife who had
given birth at home herself, and that was the
first time at the hospital I felt that someone had
understood me (Lindgren et al., 2011, p. 103).
Accepting and appreciating the care of the hos-
pital staff was a positive coping strategy used by some
women. The ability to adopt this attitude, however, was
dependent on the woman’s personality and the circum-
stances surrounding the transfer (Creasy, 1997).
Making Sense of Events
The category involves three themes: “understanding
why transfer occurred,” “acknowledging feelings of dis-
appointment,” and “moving forward.”
Understanding Why Transfer Occurred
Information and preparation provided by the midwife
at the time of transfer enhanced the women’s sense of
control (Creasy, 1997; Lindgren et al., 2011). Women
found it important to understand clearly why the trans-
fer needed to occur. Transfer to hospital was seen by
some as a threat to their ability to listen to their body
in labor, and this in turn threatened their sense of con-
trol over the situation (Lindgren et al., 2011). Women
who understood that there were clear cut indications
for transfer and interventions seemed to feel more eas-
ily ready to accept the situation (Creasy, 1997). They
were more likely to believe that the clinical picture was
beyond their control, for example,
The placenta was fixed to the womb, so it
couldn’t have come away anyway . . . I did the
important bit myself (Creasy, 1997, p. 36).
The waters broke, and . . . she very calmly just
said, “Right, the baby has poo-ed inside you, it’s
not a big deal, it’s fine. All we have to do now is
call an ambulance.” So I said, “OK, that’s fine,
not a problem” (McCourt et al., 2012, p. 8).
Acknowledging Feelings of Disappointment
A sense of loss of the plans to give birth at home and
feelings of disappointment were common. Women
described feeling that their bodies had not performed
to their expectations. Some examples of this include the
following:
I felt like I wasn’t good enough and I felt disap-
pointed that my body didn’t do what it was sup-
posed to do (Lindgren et al., 2011, p. 103).
I think there’s disappointment or a sense of loss
too. Part of me feeling disappointed in my body
. . . Loss of not doing it as I thought I could do it
(Dahlen et al., 2010, p. 1982).
Disappointment at not having the baby at home
and disappointment in their bodies manifested feelings
of lost dreams (Dahlen et al., 2010; Lindgren et al., 2011),
which were often profound. These lost dreams seemed to
create a sense of failure, that the woman’s body was not
good enough, and did not do what it was supposed to do
(Lindgren et al., 2011). Women expressed this by saying
Giving birth at home was a dream for me. I
thought of it as the best start for the baby, so it
was disappointing having to finish the birth at
the hospital (Lindgren et al., 2011, p. 103).
114  Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital  Fox et al.
For eight weeks I did not embrace motherhood
. . . I wouldn’t completely let go of my old life
without a baby and not being a mother (Dahlen
et al., 2010, p. 1982).
Moving Forward
This theme was about the women being able to process
what had occurred, by talking it through as much as
they felt was needed. One woman described feeling that
she couldn’t talk enough about it but simultaneously
was sick of talking about it because she felt the issues
remained unresolved. This process was a type of retro-
spective sense making, a justification for events.
I was just busting because I couldn’t talk enough
about this . . . I got sick of talking about it too, but
it was unresolved (Dahlen et al., 2010, p. 1981).
They would say oh! You’ve got to get on with
it. And it was like I don’t need to hear that. I’m
going to get on with it but I’d like to also say it’s
not that easy (Dahlen et al., 2010, p. 1982).
All the women in the publicly funded home birth
program, including those transferred, said they would
choose home birth again (Catling-Paull et al., 2011).
As part of the acceptance process, women looked for-
ward to trying again for a home birth with the next
pregnancy. This may be regarded as a way of helping to
validate their choice of home birth.
This time I needed some help but next time I’ll do it
at home all the way! (Lindgren et al., 2011, p. 103).
I still strongly think that home is the place to be,
yes I still will definitely plan another homebirth
(Catling-Paull et al., 2011, p. 126).
DISCUSSION
This analysis identifies, from women’s perspectives,
several potential improvements in care during transfer
to hospital from a planned home birth. Preparation
of women, through the provision of information dur-
ing the antenatal period; optimal communication and
professional behavior at the time of transfer; and the
provision of postbirth counselling may significantly
improve women’s levels of coping with unexpected
outcomes. Optimizing opportunities for the provision
of continuity of midwifery care and building a sense of
connection between women planning a home birth and
their backup hospital are organizational aspects which
may be addressed.
The findings show that receiving information dur-
ing the antenatal period is important to women. The
literature also demonstrates that antenatal education
increases maternal satisfaction with the birth experi-
ence (Walsh, 2012), reduces anxiety levels for women,
and increases partner involvement in labor and birth
(Ferguson, Davis, & Browne, 2013). The potential for
quality antenatal education to prepare couples emotion-
ally for childbirth appears to be at the heart of this asso-
ciation. Both cognitive and affective aspects are equally
important to the preparation of women and their
support people (Ferguson et al., 2013), and this may
logically be assumed to apply when assisting women to
feel ready for the possibility of transfer during or after
planned home birth.
Gaining familiarity, during the antenatal period,
with the personnel, processes, and environment of
the backup hospital seems to enhance confidence in
women and reassure their families. When women plan-
ning a home birth were prepared during pregnancy for
the possibility of transfer, and were familiar with the
hospital processes and environment, it created a sense
of safety and security for them and their families. This
familiarity may have created more realistic expectations,
which may be important for primiparous women who
have a higher likelihood of transfer than do multipa-
rous women. This sense of security was evident in the
paper about publicly funded home birth (Catling-Paull
et al., 2011). Although the Catling-Paull et al. (2011)
study was limited to multiparous women, the women’s
comments displayed a strong sense of confidence in the
hospital with which they felt connected.
The findings include quotes from several women
who described meeting with negative attitudes toward
home birth among hospital staff. This finding is of
particular concern because the behavior described con-
travenes the International Confederation of Midwives
(ICM) International Code of Ethics for Midwives (2008).
According to the code, midwives must support the right
of women and families to participate in decisions about
 Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital  Fox et al.  115
their care and must also respond to the psychological
and emotional needs of women seeking care, whatever
their circumstances.
As Dahlen et al. (2011) suggest, it may be more
appropriate for maternity care providers to reflect on
why women choose to birth outside mainstream hospital
services, than to make negative judgements about their
choices. Widely recognized is that opposing paradigms
exist around perceptions of risk and safety in relation
to maternity care (Anderson & Murphy, 1995; Ashley
& Weaver, 2012; Bick, 2012; Blix, Oian, & Kumle, 2008;
Cheyney & Everson, 2009; Foley & Faircloth, 2003;
Homer, 2010; McMurtrie et al., 2009; Walsh, 2000).
Polarization of attitudes to the safety of home birth is a
key concept in the literature (Catling-Paull et al., 2012;
Chervenak, McCullough, Brent, Levene, & Arabin, 2013;
Cheyney & Everson, 2009; Dahlen, 2012; Homer, 2010).
Issues such as hostile behaviors displayed toward women
after transfer from planned home birth are perhaps
implicitly buried in this paradigmatic problem.
Women who have chosen home birth com-
monly face challenges in advocating for their decisions,
the reasons for which are complex (Cheyney, 2008).
The process of choosing and planning a home birth
involves working outside accepted norms and navigat-
ing around obstacles in an established maternity care
system (Cheyney, 2008). Communicating with relatives,
friends, and/or health professionals about their choice
of birthplace is often problematic because the decision
to have a home birth challenges hegemonic biomedi-
cal beliefs (Cheyney, 2008; Jordan, 1997). A range of
belief systems may exist concurrently in any particular
sphere. Some views will dominate, either because they
are more efficacious or because they carry a stronger
structural power base, often both. When one view
gains acceptance, alternative types of knowledge may
become devalued. Individuals who subscribe to alterna-
tive, nonhegemonic belief systems are then sometimes
seen as uninformed, naïve, or pestilent (Jordan, 1997).
Cheyney (2011) describes choosing home birth is an act
of resistance, demonstrating avoidance of a “doctor-up,
mother-down hierarchy” (p. 531).
Cheyney (2008) applies the notion of a “systems-
challenging praxis,” a term derived from the critical
medical anthropology work of Singer (1995). According
to Cheyney (2008), cultivation of this praxis involves
three stages. The first stage involves questioning
accepted public narratives around childbirth, the second
constructing counternarratives to become empowered
and, finally, belonging to and becoming supportive of
an alternative collective belief (Cheyney, 2008). This
very process may play a role in the difficulty some
women experience during a transfer to hospital and
may even, in some cases, result in their reluctance to be
transferred. The transfer, occurring during labor, a vul-
nerable time for most women, involves a fundamental
paradigm shift to begin to accept the very systems and
values they had previously resisted. Hostile behaviors by
hospital staff are likely to exacerbate women’s feelings
of fear and vulnerability as they make the transition to
being cared for in hospital.
Access to clear and accurate information at the
time of transfer is beneficial, especially for those experi-
encing complications of a traumatic nature. Unexpected
and dramatic events, which may disrupt a woman’s
belief systems and sense of control, are likely to be
psychologically distressing (Gamble & Creedy, 2009).
Women value the opportunity to talk about events, to
accept feelings of disappointment and move on to the
next phase of their lives. This next phase will include
either transition to parenting or embarking on grief
reactions, neither of which are insignificant experiences.
Resolving issues around the birth itself is therefore
imperative. In a study by Creedy, Shochet, and Horsfall
(2000), one in three women reported a stressful birth,
as well as demonstrating three or more symptoms of
trauma within 6 weeks of birth. Of the women surveyed,
5.6% were also diagnosed with an acute posttraumatic
stress disorder (PTSD). Midwives have the opportunity
to provide emotional and psychological support for
women experiencing such distress during the postpar-
tum period. Postbirth counselling has been explored
in the literature and found to be beneficial for many
women (Fenwick et al., 2013).
For some women, transfer was largely a negative
event that resulted in varying degrees of disappoint-
ment and loss. Questions emerge as to whether a more
positive attitude to transfer could be constructed by
negotiating women’s expectations differently. Transfer
in and of itself is not a poor clinical outcome. In some
settings, early labor assessment is done at home, and no
firm decisions need to be made regarding place of birth
until labor has established (Brintworth & Sandall, 2013;
McCourt et al., 2012). Conversely, the findings show
that access to continuity of carer and the standard of
care received in hospital has an important impact on the
way women experience transfer (Creasy, 1997; Lindgren
et al., 2011).
Finally, the concept of continuity of carer and its
implications for women’s experiences emanates from
all three categories in various ways. One of the rea-
sons home birth is chosen by women is because of the
116  Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital  Fox et al.
c­ ontinuity of caregiver that is integral to the model of
care (Longworth, Ratcliffe, & Boulton, 2001). The value
of rapport, trust, and confidence that women develop
with a known midwife is widely recognized as being
associated with improved outcomes and higher mater-
nal satisfaction. A Swedish quantitative study (Lindgren
et al., 2008) found that women having their first baby
and planning a home birth were four times more likely
to be transferred to hospital if the midwife attending
the home birth was different from the midwife they
had seen during pregnancy. Although the provision of
continuity of carer may not be possible in all transfer
settings, all of the time, the findings suggest that opti-
mizing opportunities for continuity of midwifery carer
for women through the transfer process is beneficial.
There is inherent value in personalized maternity care
and this would inevitably add to the quality of support
felt by women being transferred (Creasy, 1997). In the
late 20th century, concern grew that maternity care in
many settings was becoming increasingly fragmented
(McCourt, Stevens, Sandall, & Brodie, 2006). A ground-
swell of midwifery literature evidencing and discussing
the value of midwifery continuity of care was pub-
lished around the start of the new millennium (Hatem,
­Sandall, Devane, Soltani, & Gates, 2008).
A known midwife has the capacity to enhance
communication and provide individualized information
to women at all three of the crucial stages of childbear-
ing (antenatal period, time of transfer, and postbirth).
During transfer, providing continuity of carer provides
the midwife, at the very least, the opportunity to enable
a smooth handover to hospital staff. At best, women
need not lose the care of their known midwife simply
because they require transfer. One might argue that
this is a vulnerable time when a woman needs support
and advocacy from her known midwife more than ever.
Follow up from a known midwife during the postnatal
period facilitates an opportunity for women to talk
about their experience with a trusted caregiver.
FURTHER RESEARCH
Further research is needed to explore how home birth
midwives view and experience transfer and how hospi-
tal staff encounter receiving women who are transferred
from planned home birth. Gaining understanding of
health care providers’ views and experiences may clarify
the challenges involved in transfer processes and illumi-
nate how a more collaborative service may ameliorate
some of the challenges faced.
Empirical research is needed in the Australian set-
ting to explore the views and experiences of women and
health professionals involved in home birth transfers.
Publicly funded home births in the Australian setting
will be examined specifically in relation to transfer to
hospital, as part of the Birthplace in Australia project.
The reasons for a four- to fivefold increase in
the likelihood of transfer for a primiparous women
in comparison to a multiparous woman needs further
exploration to investigate any association with poorer
outcomes for primiparous women and their babies.
CONCLUSION
This study will hopefully stimulate further discourse
around home birth transfer processes. Women’s choices
around place of birth are complex, involving social
perspectives and personal definitions of emotional
safety. Despite high transfer rates and perinatal mortal-
ity rates in some studies, many women will still choose
home birth. Understanding the views and experiences
of women who are transferred to hospital after plan-
ning a home birth is important because it may help to
inform the development of woman centered care prac-
tices and help to improve the attitudes and behaviors of
health professionals involved. Maximizing opportunities
to provide women with continuity of midwifery carer,
especially from home to hospital, may help to streamline
the transfer process and improve safety and well-being
for women and babies in such situations. Improving the
quality of care during and after transfer and maintaining
safety for women choosing home birth is paramount.
Quality and clarity of communication, feeling connected
to the backup hospital, and receiving continuity of mid-
wifery care helps make the transfer process as seamless
as possible for women. Arriving at the hospital is a time
of vulnerability and fear for women and the presence of a
known midwife will provide valuable support at this time.
New caregivers must be sensitive to the woman’s need for
reassurance and acceptance. The reasons for transfer
need to be clearly communicated to women at the time
of transfer and the circumstances fully understood in
more detail during the postpartum recovery period. This
can be done in a sensitive and individualized manner by
a known caregiver. Women need to talk through their
experience and to acknowledge their feelings of disap-
pointment to move forward in the next phase of their
lives. This synthesis aims to create a starting point toward
understanding, from women’s perspectives, how home
birth transfer processes may be improved.
 Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital  Fox et al.  117
REFERENCES
Amelink-Verburg, M. P., Verloove-Vanhorick, S. P., Hakkenberg,
R. M. A., Veldhuijzen, I. M. E., Bennebroek Gravenhorst,
J., & Buitendijk, S. E. (2008). Evaluation of 280 000 cases
in Dutch midwifery practices: A descriptive study. British
Journal of Obstetrics & Gynaecology, 115, 570–578.
Anderson, R. E., & Murphy, P. A. (1995). Outcomes of
11,788 planned home births attended by certified
nurse-midwives. A retrospective descriptive study.
Journal of Nurse-Midwifery, 40(6), 483–492. http://
dx.doi.org/10.1016/0091-2182
Ashley, S., & Weaver, J. (2012). Factors influencing multipa-
rous women to choose a homebirth—An exploratory
study. British Journal of Midwifery, 20(10), 710–715.
Bailes, A., & Jackson, M. E. (2000). Shared responsibility in
home birth practice: Collaborating with clients. Journal
of Midwifery and Women’s Health, 40, 537–543.
Bick, D. (2012). Place of birth in England: Still a contentious
issue? Midwifery, 28(1), 1–2.
Blix, E., Huitfeldt, A. S., Øian, P., Straume, B., & Kumle, M.
(2012). Outcomes of planned home births and planned
hospital births in low-risk women in Norway between
1990 and 2007: A retrospective cohort study. Sexual &
Reproductive Healthcare, 3(4), 147–153. http://dx.doi
.org/10.1016/j.srhc.2012.10.001
Blix, E., Oian, P., & Kumle, M. (2008). Outcomes after
planned home births [Utfall etter planlagte hjemmefod-
sler]. Tidsskrift for den Norske Laegeforening, 128(21),
2436–2439.
Brintworth, K., & Sandall, J. (2013). What makes a successful
home birth service: An examination of the influential
elements by review of one service. Midwifery, 29(6),
713–721. http://dx.doi.org/10.1016/j.midw.2012.06.016
Brocklehurst, P., Hardy, P., Hollowell, J., Linsell, L., Mac-
farlane, A., McCourt, C., . . . Stewart, M. (2012).
Perinatal and maternal outcomes by planned place of
birth for healthy women with low risk pregnancies:
The Birthplace in England national prospective cohort
study. British Medical Journal, 344, d7400. http:dx.doi
.org/10.1136/bmj.d7400
Catling-Paull, C., Coddington, R., Foureur, M. J., & Homer, C.
S. E. (2013). Publicly funded homebirth in Australia: A
review of maternal and neonatal outcomes over 6 years.
The Medical Journal of Australia, 198, 616–620. http://
dx.doi.org/10.5694/mja12.11665
Catling-Paull, C., Dahlen, H., & Homer, C. S. E. (2011).
Multiparous women’s confidence to have a publicly-
funded homebirth: A qualitative study. Women and
Birth, 24(3), 122–128. http://dx.doi:org/10.1016/j
.wombi.2010.09.001
Catling-Paull, C., Foureur, M. J., & Homer, C. S. E. (2012).
Publicly-funded homebirth models in Australia. Women
and Birth, 25, 152–158. http://dx.doi.org/10.1016/j
.wombi.2011.10.003
Chervenak, F. A., McCullough, L. B., Brent, R. L., Levene,
M. I., & Arabin, B. (2013). Planned homebirth: The
professional responsibility response. American Journal
of Obstetrics and Gynaecology, 208(1), 31–38. http;//
dx.doi.org/10.1016/j.ajog.2012.10.002
Cheyney, M. (2008). Homebirth as systems-challenging
praxis: Knowledge, power, and intimacy in the birth-
place. Qualitative Health Research, 18(2), 254–267.
http://dx.doi.org/10.1177/1049732307312393
Cheyney, M. (2011). Reinscribing the birthing body:
Homebirth as ritual performance. Medical Anthro-
pology Quarterly, 25(4), 519–542. http://dx.doi
.org/10.1111/j.1548-1387.2011.01183.x
Cheyney, M., & Everson, C. (2009). Narratives of
risk: Speaking across the hospital/homebirth
divide. Anthropology News, 50, 7–8. http://dx.doi
.org/10.1111/j.1556-3502.2009.50307.x
Christiaens, W., Gouwy, A., & Bracke, P. (2007). Does a referral
from home to hospital affect satisfaction with childbirth? A
cross-national comparison. BMC Health Services Research,
7, 109. http://dx.doi.org/10.1186/1472-6963-7-109
Creasy, J. M. (1997). Women’s experience of transfer from
community-based to consultant-based maternity care.
Midwifery, 13(1), 32–39. http:dx.doi.org/10.1016/
S0266-6138(97)90030-9
Creedy, D. K., Shochet, I. M., & Horsfall, J. (2000). Childbirth
and the development of acute trauma symptoms: Inci-
dence and contributing factors. Birth, 27(2), 104–111.
http://dx.doi.org/10.1046/j.1523-536x.2000.00104.x
Critical Appraisal Skills Programme. (2010). Qualitative
research checklist. Oxford, United Kingdom: CASP.
Dahlen, H. (2012). Engaging new levels of thinking to dis-
engage from conflict and create cooperation. Women
and Birth, 25(2), 51–53. http://dx.doi.org/10.1016/j
.wombi.2012.03.001
Dahlen, H. G., Barclay, L. M., & Homer, C. S. E. (2010). Pro-
cessing the first birth: Journeying into ‘motherland.’
Journal of Clinical Nursing, 19(13), 1977–1985. http://
dx.doi.org/10.1111/j.1365-2702.2009.03089.x
Dahlen, H. G., Jackson, M., & Stevens, J. (2011). Homebirth,
freebirth and doulas: Casualty and consequences of
a broken maternity system. Women and Birth, 24(1),
47–50. http://doi:10.1016/j.wombi.2010.11.002
Davies, J., Hey, E., Reid, W., & Young, G. (1996). Prospective
regional study of planned home births. British Medi-
cal Journal, 313, 1302–1306. http://dx.doi.org/10.1136/
bmj.313.7068.1302
118  Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital  Fox et al.
Davies, J. P. (1997). The midwife in the Northern region in
1993 homebirth study. British Journal of Midwifery,
5(4), 219–224.
Davis-Floyd, R. E., & Sargent, C. F. (Eds.). (1997). Childbirth
and authoritative knowledge: Cross cultural perspectives.
Berkeley, CA: University of California Press.
de Jonge, A., Mesman, J. A., Manniën, J., Zwart, J. J., van Dillen,
J., & van Roosmalen, J. (2013). Severe adverse maternal
outcomes among low risk women with planned home
versus hospital births in the Netherlands: Nationwide
cohort study. British Medical Journal, 346, f3263. http://
dx.doi.org/10.1136/bmj.f3263
de Jonge, A., van der Goes, B. Y., Ravelli, A. C., Amelink-
Verburg, M. P., Mol, B., Nijhuis, J. G., . . . Bui-
tendijk, S. E. (2009). Perinatal mortality and morbidity
in a nationwide cohort of 529,688 low-risk planned
home and hospital births. British Journal of Obstet-
rics and Gynaecology, 116, 1177–1184. http://dx.doi
.org//10.1111/j.1471-0528.2009.02175.x
Durand, A. M. (1992). The safety of home birth: The farm
study. American Journal of Public Health, 82(3),
450–453. http://dx.doi.org/10.2105?AJPH.82.3.450
Fenwick, J., Gamble, J., Creedy, D., Barclay, L., Buist, A., &
Ryding, E. L. (2013). Women’s perceptions of emo-
tional support following childbirth: A qualitative
investigation. Midwifery, 29(3), 217–224. http://dx.doi
.org/10.1016/j.midw.2011.12.008
Ferguson, S., Davis, D., & Browne, J. (2013). Does antenatal
education affect labour and birth? A structured review
of the literature. Women and Birth, 26(1), e5–e8. http://
dx.doi.org/10.1016/j.wombi.2012.09.003
Foley, L., & Faircloth, C. A. (2003). Medicine as discursive
resource: Legitimation in the work narratives of mid-
wives, Sociology of Health and Illness, 25, 165–184.
http://dx.doi.org/10.1111/1467-9566.00330
Gamble, J., & Creedy, D. K. (2009). A counselling model for
postpartum women after distressing birth experiences.
Midwifery, 25(2), e21–e30. http://dx.doi.org/10.1016/j
.midw.2007.04.004
Ghazi Tabatabaie, M., Moudi, Z., & Vedadhir, A. (2012). Home
birth and barriers to referring women with obstetric
complications to hospitals: A mixed-methods study in
Zahedan, southeastern Iran. Reproductive Health, 9, 5.
Hatem, M., Sandall, J., Devane, D., Soltani, H., & Gates, S.
(2008). Midwife-led versus other models of care for
childbearing women. Cochrane Database of System-
atic Reviews, (4), CD004667. http://dx.doi.org/10.1002/
14651858.CD004667.pub2
Homer, C. S. E. (2010). The homebirth debate in Australia: A
clash of philosophies? Precedent, 98, 38–42.
International Confederation of Midwives. (2008). Interna-
tional code of ethics for midwives. Retrieved from http://
www.internationalmidwives.org
Janssen, P. A., Carty, E. A., & Reime, B. (2006). Satisfac-
tion with planned place of birth among midwifery
clients in British Columbia. Journal of Midwifery and
Women’s Health, 51, 91–97. http://dx.doi.org/10.1016/j
.jmwh.2005.10.012
Janssen, P. A., Lee, S. K., Ryan, E. M., Etches, D. J., Farquhar-
son, D. F., Peacock, D., & Klein, M. C. (2002). Outcomes
of planned home births versus planned hospital births
after regulation of midwifery in British Columbia.
CMAJ: Canadian Medical Association Journal, 166(3),
315–323.
Janssen, P. A., Lee, S. K., Ryan, E. R., & Saxell, L. (2003). An eval-
uation of process and protocols for planned home birth
attended by regulated midwives in British Columbia.
Journal of Midwifery and Women’s Health, 48, 138–146.
http://dx.doi.org/10.1016/S1526-9523(02)00418-X
Johnson, K. C., & Daviss, B. A. (2005). Outcomes of planned
home births with certified professional midwives:
Large prospective study in North America. British
Medical Journal, 330(7505), 1416–1422. http://dx.doi
.org/10.1136/bmj.330.7505.1416
Jordan, B. (1997). Authoritative knowledge and its construc-
tion. In R. E. Davis-Floyd & C. F. Sargent (Eds.), Child-
birth and authoritative knowledge (pp. 55–79). Berkeley,
CA: University of California Press.
Lindgren, H. E., Hildingsson, I. M., Christensson, K., &
Rådestad, I. J. (2008). Transfers in planned home
births related to midwife availability and continu-
ity: A nationwide population-based study. Birth:
Issues in Perinatal Care, 35(1), 9–15. http://dx.doi
.org/10.1111/j.1523-536X.2007.00206.x
Lindgren, H. E., Rådestad, I. J., & Hildingsson, I. M. (2011).
Transfer in planned home births in Sweden—Effects
on the experience of birth: A nationwide population-
based study. Sexual & Reproductive Healthcare: Official
Journal of the Swedish Association of Midwives, 2(3),
101–105. http:dx.doi.org/10.1016/j.srhc.2011.03.001
Longworth, L., Ratcliffe, J., & Boulton, M. (2001). Inves-
tigating women’s preferences for intrapartum care:
Home versus hospital births. Health & Social Care
in the Community, 9(6), 404–413. http://dx.doi
.org/10.1046/j.1365-2524.2001.00319.x
McCourt, C., Rayment, J., Rance, S., & Sandall, J. (2012).
Organisational strategies and midwives’ readiness to
provide care for out of hospital births: An analy-
sis from the Birthplace organisational case studies.
Midwifery, 28(5), 636–645. http://dx.doi.org/10.1016/j.
midw.2012.07.004
 Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital  Fox et al.  119
McCourt, M., Stevens, T., Sandall, J., & Brodie, P. (2006).
Working with women: Developing continuity of care
in practice. In L. A. Page & R. McCandlish (Eds.), The
new midwifery: Science and sensitivity in practice (2nd
ed., pp. 141–165). London, United Kingdom: Churchill
Livingstone.
McMurtrie, J., Catling-Paull, C., Teate, A., Caplice, S.,
Chapman, M., & Homer, C. (2009). The St. George
Homebirth Program: An evaluation of the first 100
booked women. Australian & New Zealand Journal of
Obstetrics & Gynaecology, 49(6), 631–636. http:dx.doi
.org/10.1111/j.1479-828X.2009.01103.x
Murphy, P. A. (1998). Design and methodology in a com-
munity, practice-based research network: A study
of nurse-midwifery home-birth practice. Midwifery,
14(3), 155–161. http://dx.doi.org/10.1016/S0266-6138
(98)90030-4
Murphy, P. A., & Fullerton, J. (1998). Outcomes of intended
home births in nurse-midwifery practice: A prospec-
tive descriptive study. Obstetrics and Gynecology, 92(3),
461–470. http://dx.doi.org/10.1016/S00029-7844
Noblit, G. W., & Hare, R. D. (1988). Meta-ethnography: Syn-
thesizing qualitative studies. Thousand Oaks, CA: Sage.
Radoff, K. A., Levi, A., & Thompson, L. M. (2012). From
home to hospital: Mistreatment of childbearing women
and barriers to facility-based birth in Nicaragua. Inter-
national Journal of Childbirth, 2(1), 40–50. http://
dx.doi.org/10.1891/2156-5287.2.1.40
Schmied, V., Beake, S., Sheehan, A., McCourt, C., & Dykes,
F. (2011). Women’s perceptions and experiences of
breastfeeding support: A metasynthesis. Birth:
Issues in Perinatal Care, 38(1), 49–60. http://dx.doi.
org/10.1111/j.1523-536X.2010.00446.x
Singer, M. (1995). Beyond the ivory tower: Critical praxis
in medical anthropology. Medical Anthropology
Quarterly, 9(1), 80–106. http://dx.doi.org/10.1525/
maq.1995.9.1.02a00060
Thorne, S., Jensen, L., Kearney, M. H., Noblit, G., & Sand-
elowski, M. (2004). Qualitative metasynthesis: Reflec-
tions on methodological orientation and ideological
agenda. Qualitative Health Research, 14(10), 1342–1365.
http://dx.doi.org/10.1177/1049732304269888
Tyson, H. (1991). Outcomes of 1001 midwife-attended home
births in Toronto, 1983–1988. Birth, 18(1), 14–19.
http://dx.doi.org/10.1111/j.1523-536X.1991.tb00047.x
Vedam, S., Goff, M., & Marnin, V. N. (2007). Closing the the-
ory-practice gap: Intrapartum midwifery management
of planned homebirths. Journal of Midwifery & W­ omen’s
Health, 52(3), 291–300. http://dx.doi.org/10.1016/j
.jmwh.2007.02.013
Walsh, D. (2000). Evidence-based care series 1: Birth environ-
ment. British Journal of Midwifery, 8(5), 276–278.
Walsh, D. (2012). Evidence and skills for normal labour and
birth: A guide for midwives (2nd ed.). Abingdon Oxon,
United Kingdom: Routledge.
Walsh, D., & Downe, S. (2005). Meta-synthesis method
for qualitative research: A literature review. Journal
of Advanced Nursing, 50(2), 204–211. http://dx.doi
.org/10.1111/j.1365-2648.2005.03380.x
Wiegers, T. A., van der Zee, J., & Keirse, M. J. (1998). Transfer
from home to hospital: What is its effect on the experi-
ence of childbirth? Birth, 25(1), 19–24. http://dx.doi
.org/10.1046/j.1523-536x.1998.00019.x
Correspondence regarding this article should be directed to
Deborah Fox, BMid, MSc, PhD candidate, Centre for Midwifery,
Child and Family Health, Faculty of Health, University of Tech-
nology, Sydney, P.O. Box 123, Broadway, Ultimo, New South
Wales 2007 Australia. E-mail: Deborah.J.Fox@student.uts.edu.au
Deborah Fox, BMid, MSc, PhD candidate, Centre for
Midwifery, Child and Family Health, Faculty of Health,
­University of Technology, Sydney, Australia.
Athena Sheehan, BN, Master of Nursing, PhD, Associate Pro-
fessor, Centre for Midwifery, Child and Family Health, Fac-
ulty of Health, University of Technology, Sydney, Australia.
Caroline Homer, MScMed (ClinEpi), PhD, Professor, Centre
for Midwifery, Child and Family Health, Faculty of Health,
University of Technology, Sydney, Australia.
Maternal Obesity and the First Birth: A Case for
Targeted Contemporary Maternity Care
Valerie J. Slavin, Jennifer Fenwick, and Jenny Gamble

BACKGROUND:  Obesity in childbearing women is associated with poorer pregnancy and birth out-
comes, particularly caesarean section, compared with normal-weight women. The high caesarean sec-
tion rate may reflect care and outcomes which occur at the time surrounding the first birth.
AIM:  To describe the birth outcomes of extremely obese pregnant women (body mass index [BMI] of
40 or more) experiencing their first birth.
METHODS:  Clinical audit was used to systematically review the care and birth outcomes of all
extremely obese pregnant women experiencing their birth at one study site during a 2-year period in
2009 and 2010. Fifty participants birthed during the study period. Data were collected from booking to
discharge from the maternity service and included variables such as model of care, number of appoint-
ments, and obstetric and neonatal outcomes. Descriptive statistics were used to describe and synthesize
the data. Inferential statistics were used to draw inferences about the population.
RESULTS:  Obese women rarely had contact with a midwife, except at booking, receiving a standard
model of care provided by numerous caregivers, most often inexperienced medical staff. More than
half of the obese women experienced a caesarean section (56%), 2.3 times that of normal-weight pri-
miparous women who birthed at the study site during the same period (24.2%). This was despite 64%
experiencing normal pregnancy free from any complication. For women who planned to labor, birth
intervention including induction of labor, augmentation for slow labor, epidural, and continuous car-
diotocography was high. Caesarean occurred most often for “failure to progress” and “failed induction.”
CONCLUSION:  Clinical audit was useful in determining information, which suggests current mater-
nity care provision is not meeting the needs of extremely obese women experiencing their first birth.
IMPLICATIONS FOR PRACTICE:  The development of effective, targeted antenatal care designed to
meet the needs of extremely obese women is recommended as are strategies to keep birth normal.
Keywords:  pregnancy; body mass index; morbid obesity; caesarean section; gestational diabetes;
cardiovascular pregnancy complications

INTRODUCTION (Centre for Maternal and Child Enquiries [CMACE],

The prevalence of maternal obesity is increasing expo-
nentially with reports of it reaching epidemic propor-
tions throughout the developed world, mirroring that of
obesity in the general population (World Health Orga-
nization [WHO], 2012). This is concerning given that
maternal obesity is now recognized as a key risk factor
for adverse outcomes for both women and their babies
2011) such as hypertensive disorders (Abenhaim,
Kinch, Morin, Benjamin, & Usher, 2007; Dodd, Grivell,
Nguyen, Chan, & Robinson, 2011; Knight, Kurinczuk,
Spark, & Brocklehurst, 2010; Mbah et al., 2010), diabe-
tes (Abenhaim et al., 2007; Athukorala, Rumbold, Will-
son, & Crowther, 2010; Dodd et al., 2011; Knight et al.,
2010), thromboembolism (CMACE, 2011), and caesar-
ean section (CS). The number of women e­ xperiencing

INTERNATIONAL JOURNAL OF CHILDBIRTH Volume 4, Issue 2, 2014

© 2014 Springer Publishing Company, LLC www.springerpub.com
120 http://dx.doi.org/10.1891/2156-5287.4.2.120

CS has been shown to increase in a dose-related fashion
with increasing body mass index (BMI; Abenhaim
et al., 2007; Bhattacharya, Campbell, Liston, & Bhat-
tacharya, 2007; Chu et al., 2007; Khashan & Kenny,
2009; Knight et al., 2010; Mantakas & Farrell, 2010;
Mbah et al., 2010; Poobalan, Aucott, Gurung, Smith,
& Bhattacharya, 2009; Sebire et al., 2001; Usha Kiran,
Hemmadi, Bethel, & Evans, 2005). Work undertaken
with Australian childbearing women has demonstrated
comparable trends (Athukorala et al., 2010; Dodd et al.,
2011). Similarly, health statistics data obtained for one
hospital in South East Queensland revealed that in 2010,
the CS rate for normal-weight women (BMI of 19–24)
was 24.5%, increasing exponentially with BMI to 29.1%
for BMI of 25–29, 32.9% for BMI of 30–34, 33.3% for
BMI of 35–39, and 43.8% for BMI of 40 or more (Health
Statistics Centre Queensland Health, 2012).
In addition, there is a growing body of evidence that
identifies a strong association between primiparity and
increased CS rates in obese women. A systematic review
of 11 studies (N 5 209,193) conducted by Poobalan et al.
(2009) reported obese primiparous women (defined as
BMI of 35 or more) were three times more likely to expe-
rience CS compared with their normal-weight counter-
parts (crude pooled odds ratio 3.38, 95% CI [2.49, 4.57]).
Similar results are reported by others (Bhattacharya et al.,
2007). Although there is no doubt that maternal ill health
and subsequent concerns for the fetus are likely to play
some part in the increased rates of CS, the sheer number
of caesareans in this group of women suggests that there
may be other contributing factors.
One of the most important strategies for reducing
the overall CS rate is to reduce the number of primary CSs.
Gaining a better understanding of all the factors associ-
ated with a primary caesarean in this group of women
may assist health care professionals improve the quality
of maternity care and ultimately, a woman’s reproductive
health.
Although there is a lack of evidence pertaining to
the care and outcomes of women with very severe obesity
(defined as BMI of 40 more; WHO, 2000), there is also
no agreed term to describe obesity subgroups beyond this
BMI. Recent work describing the prevalence and outcomes
of women with a BMI of 50 or greater have used various
terms including super obese, morbid obese, or extremely
obese (Australasian Maternity Outcomes Surveillance Sys-
tem, 2010; Knight et al., 2010; Mbah et al., 2010). Because
there is currently no standard agreed terms, this article
will define subgroups not currently described elsewhere as
moderately obese (BMI of 40–44), extremely obese (BMI
of 45–49), and super-extremely obese (BMI of 50 or more).
Obese Primiparous Women  Slavin et al.  121
AIM
This article presents the birth outcomes of moderate to
super-extremely obese pregnant women (BMI of 40 or
more) experiencing their first birth. The results are part
of a larger study exploring the health service usage and
outcomes of extremely obese Australian women (Slavin,
Fenwick, & Gamble, 2013).
Ethical Approval
Ethical approval to conduct the project was granted by
the Hospital District Human Research Ethics Commit-
tee (HREC) and Griffith University HREC.
METHOD
This study used a retrospective, clinical observation
research design.
Setting
The study was carried out at one maternity unit in South
East Queensland, Australia. The unit manages low-,
medium-, and selected high-risk pregnancies for approxi-
mately 3,500 women per year. Midwife-led antenatal care
is offered to women with no medical or obstetric compli-
cations. Specialist care is provided to women who have
identified risk factors and/or who develop complications
during pregnancy including women with moderate to
extreme obesity. Between 2009 and 2010, 6,995 women
birthed at the study site. This included 3,082 (44.1%)
women experiencing their first birth, which is only slightly
higher than the national average of 41.6% (Li, McNally,
Hilder, & Sullivan, 2011). A further 3,913 (55.9%) women
experienced their second or subsequent births. The over-
all prevalence of moderate to super-extremely obese
women (BMI of 40) was 21.9 per 1,000, (n 5 153; Health
Statistics Centre Queensland Health, 2010).
Sample
The primary target population was 50 pregnant women
experiencing their first birth with a self-reported pre-
pregnancy booking BMI of 40 who birthed at the study
site between January 1, 2009 and December 31, 2010.
This represents 32.7% of the larger group.
122  Obese Primiparous Women  Slavin et al.

Data Collection TABLE 1 Overview: Antenatal Visits Experienced

by Obese Women
Using a specifically designed audit tool, clinical audit ANTENATAL (AN) Mdn
was used to identify several outcome variables including ­APPOINTMENTS N 5 50 % (RANGE)
maternity service use and birth outcomes from booking
Booking gestation (weeks) 20 (8–38)
to discharge from maternity care (Slavin, Fenwick, &
Number of AN visits 12 (1–21)
Gamble, 2013).
Number of staff seen 6 (1–16)
Number of GP visits 43 86 5 (0–15)
Number of midwife visits 49 98 1 (0–7)
Data Analysis
Number of junior doctor visitsa 43 86 2 (0–7)
Number of senior doctor visitsb 37 74 1 (0–8)
Data were entered into Statistical Package for the Social
Number of obstetric consultant  7 14 0 (0–2)
Sciences (SPSS) database version 19. Descriptive statis-  visits
tics were initially used to describe and synthesize the Number of failure to attend 26 54 1 (0–5)
data. Inferential statistics were subsequently used to  visitsc
make inferences about the population. Relationships AN education classes 24 48
between categorical variables were examined using chi-
Note. GP 5 general practitioner.
square analyses, between continuous variables using a
Resident, intern, junior house officer. bRegistrar, primary health
Pearson’s product–moment correlation test and for rela- ­organization. cExcludes two stillbirths.
tionship between continuous and categorical variables
using one-way analysis of variance (ANOVA). An alpha at their booking visit. In this group of first-time moth-
level of 0.05 was used for all statistical tests. Outcome ers, the nonattendance rate was 55.3%, five times the
measures were defined according to the definitions nonattendance rate of the general maternity popula-
within the literature. tion during the same period (10.8%; Decision Support
Services Queensland Health, 2012). Just less than half
the women attended some form of antenatal education
RESULTS
classes (n 5 24, 48%).
Although 32 women (64%) experienced normal,
Participant Characteristics healthy pregnancies free from complications, 8 (16%)
women developed or were treated for hypertension and
Fifty moderate to super-extremely obese women birthed 10 (20%) for diabetes. The development or treatment of
their first baby during the study period. The average age both diabetes and hypertension was rare (n 5 2, 4%).
of participants was 28 years (SD 5 5), which is the same
as the Australian national average for 2009 (Li et al.,
2011). Most women were in the moderate obese group Birth Outcomes
(BMI of 40–44; n 5 37, 74%), with the remaining 26%
Labor
of women being in the extreme to super-extreme obese
Only 17 (34%) women experienced spontaneous onset
groups.
of labor, whereas 25 (50%) experienced an induction
of labor (IOL). The most common reason for IOL was
Antenatal: Model of Care postdates pregnancy (n 5 8, 32%). Hospital policy at the
time of data collection was routine IOL at term plus 10
Women generally booked for maternity care at 20 days regardless of cervical favorability. The other main
weeks’ gestation (range 5 8–38 weeks) and attended reasons for induction were diabetes (n 5 6, 24%), prela-
12 (range 5 1–21) antenatal visits. Most women expe- bor rupture of membranes (n 5 5, 20%), and hyper-
rienced shared care with their general practitioner tensive disease (n 5 3, 12%). One woman was induced
attending the hospital at some point during their preg- following an intrauterine fetal death at 27 weeks’ gesta-
nancy. When women did attend the hospital antenatal tion. Eight separate reasons were provided for IOL.
clinic, they were seen by several different clinicians Four women who commenced the induction pro-
(n  5 6, 1–16; see Table 1), most of whom were medical cedure with the administration of vaginal synthetic
staff in various stages of their training program (resi- prostaglandin did not dilate sufficiently to allow arti-
dents and registrars). Most women only saw a midwife ficial rupture of membranes (ARM). A further two
 Obese Primiparous Women  Slavin et al.  123

women did experience ARM and synthetic oxytocin TABLE 3  Indication for Caesarean Section
infusion but did not establish in labor. All four women (Elective and Emergency; N 5 28)
subsequently experienced a CS for “failed IOL.” ELECTIVE EMERGENCY
For women who experienced labor (n 5 38), birth  (N 5 7) (N 5 21)
interventions were high. In addition to the high IOL  n (%) n (%)
rate, a further 13 (34.2%) women experienced augmen- Failure to progress   10 (35.7)
tation with either ARM and/or synthetic oxytocin infu- Failed IOL   6 (21.4)
sion following a diagnosis of dysfunctional labor. Fetal distress   4 (14.3)
Although 19 women (50%) had an epidural sited Breech   2 (7.1) 1a (3.6)
during labor, which subsequently lead to electronic fetal Maternal request   2 (7.1)
monitoring using continuous cardiotocography (CTG), Vasa praevia   1 (3.6)
almost all the women (95%) with a live fetus were moni- Macrosomia   1 (3.6)
tored in this way. Most babies were monitored directly High head   1 (3.6)
using a fetal scalp electrode (n 5 25, 65.8%). Perhaps Note. IOL 5 induction of labor.
not surprisingly, less than 40% of the women were a
Planned elective CS for breech; progressed to emergency CS following
reported to be mobile in labor (15 out of 38, 39.5%). spontaneous labor.

For the 20 unplanned CS, there were eight different

Birth Mode reasons documented. However, “failure to progress” and
Twenty-two women birthed vaginally (spontaneously “failed induction” were the most common and accounted
[n 5 15, 30%], assisted [n 5 7, 14%]; see Table 2). In for more than half of the caesareans performed. Breech
total, 28 women (56%) birthed their baby by CS. This presentation and “maternal request” accounted for more
is almost 2.5 times that of normal-weight primiparous than half of all elective procedures (see Table 3). No
women at the study site during the same period. Of the woman was documented as having a planned elective CS
1,386 normal-weight (defined as BMI of 20–24) pri- for the comorbidities associated with obesity.
miparous women, 335 (24.2%) experienced CS. When comparing women who birthed vaginally
Seven women experienced planned elective to women who birthed by CS following planned labor
CS, and a further 21 experienced emergency CS (see (excluding planned elective CS), the groups of women
Table  3). One woman in the emergency group was were similar in many respects. There was no significant
booked for elective surgery for breech but experienced difference in maternal age, infant birth weight, onset of
emergency CS following the onset of spontaneous labor. labor, epidural, diabetes, or hypertension for women
who birthed vaginally or by CS. Furthermore, there
TABLE 2 Overview: Labor Onset and Mode of was no significant association between BMI group and
Birth for Women Experiencing Their First Birth mode of birth x2(2, [n 5 42] 5 .81, p 5 .67, Cramér’s
N 5 50 % M (SD) V 5 .14).
Age (years) 28.4 (5.3)
Onset of labor
 Spontaneous 17 34
Neonatal Outcomes
  Induction of labor 25 50
There were 50 babies born including 2 stillborn babies
  Elective caesarean  8 16 born at 22 and 27 weeks’ gestation. This is a concerning
Mode of birth finding because the stillbirth rate of 40 per 1,000 births
 Spontaneous vaginal 15 30 is more than five times that of the general Australian
 birth population (4% vs. 0.78%, retrospectively; Li et al.,
  Vaginal (vacuum)  4  8 2011). Live babies were generally born in good condi-
  Vaginal (forceps)  3  6 tion, with 5 out of 48 (10.4%) babies requiring neonatal
  Caesarean section 28 56 resuscitation. Although 4 out of 48 (8.3%) required
BMI group intermittent positive pressure ventilation via bag and
 40–44 37 74 mask, this is only slightly higher than the general popu-
 45–49  6 12
lation of 7.2% (Li et al., 2011). One baby (2.1%) required
  50  7 14
cardiac compressions, which is six times higher than the
Note. BMI 5 body mass index. general population of 0.3% (Li et al., 2011).
124  Obese Primiparous Women  Slavin et al.
Twenty-seven (56.3%) babies were admitted to or
were cared for by the special care nursery. Main reasons
were maternal diabetes (n 5 7), suspected infection
(n  5 6), and macrosomia (birth weight more than
4,500 g; n 5 5). Two live-born babies were premature
at 35 and 36 weeks’ gestation. Average birth weight was
3,720 g (SD 5 519 g).1
DISCUSSION
The results reported in this article demonstrate that
moderate to super-extremely obese women having their
first baby commonly experience quite different birth
outcomes to those of normal-weight women and the
general population. Although the overall CS rate for pri-
miparous women in Australia is 32.8% (Li et al., 2011)
and for the study site for the same period was 26.6%, the
CS rate for the cohort of women in this study was more
than double (56%). This was despite 64% of the women
experiencing normal, healthy pregnancies free from
complications other than obesity itself.
For women who planned to labor, birth interven-
tions were high. For example, almost 60% of these women
experienced an induction. Although the authors of two
systematic reviews (Caughey et al., 2009; Gülmezoglu,
Crowther, & Middleton, 2006) concluded that IOL does
not increase the CS rate, a significant methodological
critique of this work calls into question the appropriate-
ness of routine IOL for well women and fetuses before 42
weeks’ gestation (King, Pilliod, & Little, 2010; Mozurke-
wich, Chilimigras, Koepke, Keeton, & King, 2009). There
is also increasing evidence that primiparous women
having an IOL are the largest group contributing to the
CS rate (Brennan, Murphy, Robson, & O’Herlihy, 2011;
Slavin & Fenwick, 2012). Certainly, one could argue
that the risk of stillbirth in extremely obese pregnant
women perhaps justifies IOL. Clinicians, however, need
to assist women carefully weigh up the risks because sur-
gical birth itself is associated with increased morbidity
especially in this group of women (Belizán, Althab­e, &
­Cafferata, 2007; Stivanello et al., 2010).
Similarly, rates of augmentation for dysfunctional
labor were also high in this study with more than 90% of
women experiencing either IOL or augmentation. With
a strong association between the use of Syntocinon and
increased perceptions of pain, it is not surprising that
half the women used epidural for pain management
(Hildingsson, Karlström, & Nystedt, 2011). Likewise,
the use of continuous fetal monitoring (CTG) was high
with all but two women being monitored in this way.
Although there are often concerns with being able to
accurately listen and record fetal heart rates in extremely
obese women, the use of CTG is strongly associated with
increased rates of CS (Alfirevic, Devane, & Gyte, 2006).
In light of the increasing CS rate, there is currently
an international drive to “keep birth normal” particu-
larly during the first birth (Commonwealth of Australia,
2011; NSW Department of Health, 2010; Maternity
Care Working Party, Royal College of Midwives, Royal
College of Obstetricians and Gynaecologists, National
Childbirth Trust, 2007). The results of this study add to
the existing literature and support the need to keep birth
normal and avoid unnecessary interventions especially
in obese women having their first baby. In this group
of childbearing women, although some might argue
that birth interventions should be considered “part and
parcel” of care, the dilemma of whether such interven-
tion acts as a paradox or panacea appears clear. Obese
women experienced very high rates of birth interven-
tion including IOL, augmentation, epidural, and CTG
use. Although there is now increasing evidence to sug-
gest IOL should be reserved only for those women with
clear medical indications, the obese women in this study
experienced IOL for a myriad of ambiguous reasons.
Given the evidence, one could postulate that the high
rate of medical intervention that occurred during labor
may in fact be a mediating factor contributing to the
high CS rate experienced by primiparous obese women
who plan to labor. Consequently, there is a need to iden-
tify strategies aimed at reducing unnecessary interven-
tions in labor especially for those women experiencing
their first labor and birth.
Antenatal Care—A Gift or Pandora’s Box?
Although each woman’s pregnancy, labor, and birth pro-
cess contribute to her birth outcomes, there is now a sub-
stantial body of evidence that suggests that how women
are cared for during their pregnancy and labor can
significantly affect their birth outcomes. For example,
continuity of midwifery care is associated with reduced
birth interventions (Hodnett, Gates, Hofmeyr, Sakala, &
Weston, 2011; Jackson et al., 2003) as well as increased
vaginal birth rates, reduced CS rates, and reduced spe-
cial care nursery admissions (Hartz, Foureur, & Tracy,
2012; Hatem, Sandall, Devane, Soltani, & Gates, 2008;
Henderson, Hornbuckle, & Doherty, 2007; Sandall,
Soltani, Gates, Shennan, & Devane, 2013; Turnbull et
al., 2009). The women in this study predominantly
experienced fragmented medical care. When accessing

hospital care, these women were mainly seen by medi-
cal practitioners still in various stages of their training
program with limited midwifery as well as consultant
input. The care received by the women included in this
study mirrors that of the general maternity population
within the study site. Most women who currently attend
hospital for pregnancy care receive limited continuity
of care in busy clinics. Medical clinics are routinely
overbooked with no midwifery support. Women who
develop complex needs therefore often receive no mid-
wifery care. The findings of this study may therefore be
seen in other high-risk groups of women who receive
routine hospital-based obstetric care.
The number of women not attending appoint-
ments was also significant. For example, more than half
the women (n 5 26, 55%) had missed appointments
with 13 women missing two or more appointments. This
is five times the rate in the general pregnant population
(10.8%; Decision Support Services Queensland Health,
2012). There may have been a myriad of reasons for
this outcome such as lack of transport and poor social
circumstances. Given the high numbers, one could
also postulate that perhaps nonattendance reflected
dissatisfaction with service provision. Certainly, those
challenging standard systems of medicalized maternity
care would suggest this model of antenatal care to be
somewhat dysfunctional with multiple care providers;
time constraints; limited resources; and unclear aims,
values, and philosophies influencing the care provided
(Dahlen, Barclay, & Homer, 2010b; Homer, Brodie, &
Leap, 2008; Page, 2008). Australian researchers Hartz
et al. (2012) described standard care as “predominantly
fragmented, organisation and/or practitioner-centric”
(p. 40). The women in this study received medicalized,
fragmented antenatal care. Midwifery care was all but
nonexistent except for the booking visit. Within this
context, it is likely that little attention was paid to their
individual needs and preferences, quality preparation
for birth, or women’s knowledge or understanding of the
maternity care system.
Implication for Practice
To meet the needs of obese women experiencing their
first pregnancy and birth, targeted maternity care may
be the answer. Targeted maternity care has been shown
to be an effective strategy in meeting the needs of
several vulnerable groups of women (Grady & Bloom,
2004; Ickovics et al., 2003). Our work suggests that pri-
miparous women with a BMI of 40 or more should be
Obese Primiparous Women  Slavin et al.  125
viewed as a vulnerable group for several reasons. First,
maternal obesity is associated with a higher incidence
of depression particularly in adolescent females (Picker-
ing, Grant, Chou, & Compton, 2007; Blaine, Rodman,
& Newman, 2007), cigarette smoking, (Cupul-Uicab et
al., 2012), domestic violence (Huang, Yang, & Omaye,
2011), asthma (Benninger & McCallister, 2010), and
obstructive sleep apnea (Ursavas, Karadag, Nalci, Ercan,
& Gozu, 2008), all of which can have serious nega-
tive sequelae for the growing fetus. Second, compared
to multiparous women and in fact regardless of BMI,
primiparous women may require additional support
during pregnancy as well as labor and birth. This is a
view shared by others (Dahlen, Barclay, & Homer, 2008;
Miller & Skinner, 2012). For example, Dahlen, Barclay,
and Homer (2010a) found that first-time pregnant
women reacted to the unknown of labor quite differ-
ently to those women experiencing a subsequent birth.
The level of preparation, support, information, com-
munication, choices, and sense of control all explained
the diversity in the first-time experiences of birthing
women. American authors Fair and Morrison (2012)
similarly found that first-time pregnant women’s per-
ception of being in control significantly predicted birth
satisfaction with high levels of correlating satisfaction
levels. The work of both Schempf and Strobino (2009)
and Goler, Armstrong, Taillac, and Osejo (2008) takes
this one step further, suggesting that women who
develop a high internal loci of control during the antena-
tal period are also more likely to be receptive to positive
health modifications and strategies which ultimately
contribute to better birth outcomes and increased birth
satisfaction.
Thus, maternal obesity together with primipar-
ity represents a complex issue which requires a holistic
approach to care. With this in mind, a contemporary
approach to antenatal care provision for extremely
obese pregnant women experiencing their first preg-
nancy may be the answer. This is not a new idea with
specifically developed programs, such as centering in
pregnancy focusing on other specific groups of women
showing improved perinatal outcomes (Grady & Bloom,
2004; Ickovics et al., 2007). Whereas medically focused
antenatal care aims to identify and manage potential
complications, midwifery care focuses on providing
woman-centered care using a holistic approach. A
reconceptualization of antenatal care provision, draw-
ing on the skill set of both professional groups, to better
meet the needs of obese women may improve outcomes
and be more acceptable to women, possibly resulting
in positive experiences and improved birth outcomes.
126  Obese Primiparous Women  Slavin et al.
Although the numbers included in this clinical observa-
tional study are small, the findings do support the need
for further research, which should include the develop-
ment and testing of appropriate interventions (such as
models of care) to identify the most effective way to
meet the needs of this client group.
LIMITATIONS
Potential limitations and biases included inconsistency
in data presentation. Although the Queensland Perina-
tal Data form requests prepregnancy weight and height
to calculate BMI, clinical audit consistently identified
booking weight as being recorded rather than prepreg-
nancy weight resulting in the more serious systematic
error. This is, however, a consistent finding reported
by others (CMACE, 2010). In addition, retrospective
cohort data is primarily based on perinatal databases.
A recent review of Australian maternity data collec-
tions identified significant gaps in available data, with
models of maternity care and continuity of care often
poorly reported (Australian Institute of Health and
Welfare, 2011). A further limitation may be sample bias.
Although data were collected over a 2-year period in an
effort to increase numbers, the sample size remained
small and the power may not have been sufficient to
identify statistical differences within the groups. In
addition, only collecting data from one study site limits
the generalization of the findings.
CONCLUSION
This study has identified that current service provision
to extremely obese women experiencing their first birth
at the study site may be contributing to suboptimal
outcomes. The high stillbirth rate is an alarming find-
ing and warrants urgent further research in this area. To
improve outcomes, and reduce the CS rate, maternity
providers need to use a primary health care approach
to identify possible strategies which will be acceptable
to obese women. The development of targeted mater-
nity care aimed at meeting the needs of obese women
experiencing their first birth may well be the answer
to improving both outcomes and satisfaction for obese
women. To inform service development, research needs
to focus on identifying what service provision would
most likely be used by this group of women. Qualitative
studies are therefore required to answer this question for
local populations.
NOTE
1. Excludes two extremely premature stillborn babies
born at 22 and 27 weeks’ gestation.
REFERENCES
Abenhaim, H. A., Kinch, R. A., Morin, L., Benjamin, A., &
Usher, R. (2007). Effect of prepregnancy body mass
index categories on obstetrical and neonatal outcomes.
Archives of Gynecology and Obstetrics, 275(1), 39–43.
http://dx.doi.org/10.1007/s00404-006-0219-y
Alfirevic, Z., Devane, D., & Gyte, G. (2006). Continuous
cardiotocography (CTG) as a form of electronic fetal
monitoring (EFM) for fetal assessment during labour.
Cochrane Database of Systematic Reviews, (3), CD006066.
http://dx.doi.org/10.1002/14651858.CD006066
Athukorala, C., Rumbold, A. R., Willson, K. J., & Crowther,
C. A. (2010). The risk of adverse pregnancy outcomes
in women who are overweight or obese. BMC Preg-
nancy & Childbirth, 10, 56. Retrieved from http://www
.biomedcentral.com/1471-2393/10/56
Australasian Maternity Outcomes Surveillance System. (2010).
Current studies: Women with morbid obesity. Retrieved
from http://www.amoss.com.au/page.php?id=38
Australian Institute of Health and Welfare. (2011). Maternity data
in Australia: A review of sources and gaps (AIHW Bulletin
No. 87. Cat. No. AUS 136). Canberra, Australia: Author.
Belizán, J. M., Althabe, F., & Cafferata, M. L. (2007). Health
consequences of the increasing caesarean section rates.
Epidemiology, 18(4), 485–486.
Benninger, C., & McCallister, J. (2010). Asthma in pregnancy.
The Nurse Practitioner, 35(4), 10–19. doi: 10.1097/01.
npr.0000369937.32234.05
Bhattacharya, S., Campbell, D. M., Liston, W. A., & Bhatta­
charya, S. (2007). Effect of body mass index on preg-
nancy outcomes in nulliparous women delivering
singleton babies. BMC Public Health, 7, 168–175.
Blaine, B. E., Rodman, J., & Newman, J. M. (2007). Weight
loss treatment and psychological well-being: A review
and meta-analysis. Journal of Health Psychology, 12(1),
66–82. doi: 10.1177/1359105307071741
Brennan, D. J., Murphy, M., Robson, M. S., & O'Herlihy, C.
(2011). The singleton, cephalic, nulliparous woman
after 36 weeks of gestation: Contribution to over-
all cesarean delivery rates. Obstetrics and Gynecology,
117(2, Part 1), 273–279.
Caughey, A., Sundaram, V., Kaimal, A., Gienger, A., Cheng, Y.,
McDonald, K., . . . Bravata, D. (2009). Systematic review:
Elective induction of labor versus expectant management
of pregnancy. Annals of Internal Medicine, 151, 252–263.

Centre For Maternal and Child Enquiries. (2010). Maternal
obesity in the UK: Findings from a national project.
London: Author.
Centre for Maternal and Child Enquiries. (2011). Saving
mothers’ lives: Reviewing maternal deaths to make
motherhood safer: 2006–2008. The eighth report on
confidential enquiries into maternal deaths in the
United Kingdom. British Journal of Obstetrics and Gyn-
aecology, 118(Suppl. 1), 1–203.
Chu, S. Y., Kim, S. Y., Lau, J., Schmid, C. H., Dietz, P. M., Cal-
laghan, W. M., & Curtis, K. M. (2007). Maternal obesity
and risk of stillbirth: A metaanalysis. American Journal
of Obstetrics and Gynecology, 197(3), 223–228. http://
dx.doi.org/10.1016/j.ajog.2007.03.027
Commonwealth of Australia. (2011). National maternity ser-
vices plan 2010. Barton, Australia: Author.
Cupul-Uicab, L. A., Skjaerven, R., Haug, K., Melve, K. K.,
Engel, S. M., & Longnecker, M. P. (2012). In utero
exposure to maternal tobacco smoke and subsequent
obesity, hypertension, and gestational diabetes among
women in the MoBa cohort. Environmental Health Per-
spectives, 120(3), 355. doi: 10.1289/ehp.1103789
Dahlen, H. G., Barclay, L. M., & Homer, C. (2008). Preparing for
the first birth: Mothers’ experiences at home and in hos-
pital in Australia. Journal of Perinatal Education, 17(4),
21–32. http://dx.doi.org/10.1624/105812408x364143
Dahlen, H. G., Barclay, L. M., & Homer, C. S. E. (2010a).
‘Reacting to the unknown’: Experiencing the first birth
at home or in hospital in Australia. Midwifery, 26(4),
415–423. http://dx.doi.org/10.1016/j.midw.2008.07.009
Dahlen, H. G., Barclay, L. M., & Homer, C. S. E. (2010b). The
novice birthing: Theorising first-time mothers’ experi-
ences of birth at home and in hospital in Australia.
Midwifery, 26(1), 53–63. http://dx.doi: .org/10.1016/j.
midw.2008.01.012
Decision Support Services Queensland Health. (2012). Births,
mothers and outpatient research. Births and deliveries
between 01/01/2009 to 31/12/2010.
Dodd, J. M., Grivell, R. M., Nguyen, A. M., Chan, A., & Rob-
inson, J. S. (2011). Maternal and perinatal outcomes by
body mass index. Australian & New Zealand Journal of
Obstetrics & Gynaecology, 51, 136–140.
Fair, C. D., & Morrison, T. E. (2012). The relationship between
prenatal control, expectations, experienced control,
and birth satisfaction among primiparous women.
Midwifery, 28(1), 39. http://dx.doi.org/10.1016/j.
midw.2010.10.013
Goler, N. C., Armstrong, M. A., Taillac, C. J., & Osejo, V. M.
(2008). Substance abuse treatment linked with prenatal
visits improves perinatal outcomes: A new standard.
Journal of Perinatology, 28(9), 597–603. http://dx.doi.
org/10.1038/jp.2008.70
Obese Primiparous Women  Slavin et al.  127
Grady, M. A., & Bloom, K. C. (2004). Pregnancy outcomes of
adolescents enrolled in a CenteringPregnancy program.
Journal of Midwifery & Women’s Health, 49(5), 412–420.
http://dx.doi.org/10.1016/j.jmwh.2004.05.009
Gülmezoglu, A., Crowther, C., & Middleton, P. (2006). Induc-
tion of labour for improving birth outcomes for women
at or beyond term. Cochrane Database of Systematic
Reviews, (4), CD004945. http://dx.doi.org/10.1002/
14651858.CD004945.pub2
Hartz, D. L., Foureur, M., & Tracy, S. K. (2012). Australian
caseload midwifery: The exception or the rule. Women
and Birth, 25(1), 39–46. http://dx.doi.org/10.1016/j.
wombi.2011.01.001
Hatem, M., Sandall, J., Devane, D., Soltani, H., & Gates, S.
(2008). Midwife-led versus other models of care for
childbearing women. Cochrane Database of System-
atic Reviews, (4), CD004667. http://dx.doi.org/10.1002/
14651858.CD004667.pub2
Health Statistics Centre Queensland Health. (2010). Mothers
by BMI and method of birth, Gold Coast Hospital and
Birth Centre, Queensland 2009. Extracted May 20, 2010.
Health Statistics Centre Queensland Health. (2012). Perinatal
statistics Queensland 2010: Queensland health. Brisbane,
Queensland: Queensland Health.
Henderson, J., Hornbuckle, J., & Doherty, D. (2007). Models
of maternity care: A review of the evidence. Western
Australia Department of Health. Retrieved from http://
www.healthnetworks.health.wa.gov.au/docs/Models_
of_Maternity_Care_Review_of_Evidence.pdf
Hildingsson, I., Karlström, A., & Nystedt, A. (2011). Women’s
experiences of induction of labour—Findings from a
Swedish regional study. Australian & New Zealand Jour-
nal of Obstetrics & Gynaecology, 51(2), 151–157. http://
dx.doi.org/10.1111/j.1479-828X.2010.01262.x
Hodnett, E., Gates, S., Hofmeyr, G., Sakala, C., & Weston, J.
(2011). Continuous support for women during childbirth.
Cochrane Database of Systematic Reviews, (2), CD003766.
http://dx.doi.org/10.1002/14651858.CD003766.pub3
Homer, C., Brodie, P., & Leap, N. (2008). Midwifery continuity
of care: A practical guide. Sydney, Australia: Churchill
Livingstone.
Huang, H. Y., Yang, W., & Omaye, S. T. (2011). Intimate
partner violence, depression and overweight/obesity.
Aggression and Violent Behavior, 16(2), 108–114. doi:
10.1016/j.avb.2010.12.005
Ickovics, J. R., Kershaw, T. S., Westdahl, C., Magriples, U.,
Massey, Z., Reynolds, H., & Rising, S. S. (2007). Group
prenatal care and perinatal outcomes: A randomized
controlled trial. Obstetrics & Gynecology, 110(2), 330–
339. http://dx.doi.org/10.1097/AOG.0b013e31816bf6bd
Jackson, D. J., Lang, J. M., Swartz, W. H., Ganiats, T. G., Fuller-
ton, J., Ecker, J., & Nguyen, U. (2003). Outcomes, safety,
128  Obese Primiparous Women  Slavin et al.
and resource utilization in a collaborative care birth cen-
ter program compared with traditional physician-based
perinatal care. American Journal of Public Health, 93(6),
999–1006. http://dx.doi.org/10.2105/ajph.93.6.999
Khashan, A. S., & Kenny, L. C. (2009). The effects of maternal
body mass index on pregnancy outcome. European
Journal of Epidemiology, 24(11), 697–705. http://dx.doi
.org/10.1007/s10654-009-9375-2
King, V. J., Pilliod, R., & Little, A. (2010). Rapid review:
Elective induction of labor. Portland, OR: Center for
Evidence-based Policy.
Knight, M., Kurinczuk, J., Spark, P., & Brocklehurst, P. (2010).
Extreme obesity in pregnancy in the United Kingdom.
Obstetrics & Gynecology, 115(5), 989–997.
Li, Z., McNally, L., Hilder, L., & Sullivan, E. (2011). Australia’s
mothers and babies 2009 (Perinatal Statistics Series No.
25. Cat. No. PER 52). Sydney, Australia: Australian
Institute of Health and Welfare, National Perinatal Epi-
demiology and Statistics Unit.
Mantakas, A., & Farrell, T. (2010). The influence of increas-
ing BMI in nulliparous women on pregnancy outcome.
European Journal of Obstetrics, Gynecology, and Repro-
ductive Biology, 153, 43–46.
Maternity Care Working Party, Royal College of Midwives,
Royal College of Obstetricians and Gynaecologists,
National Childbirth Trust. (2007). Making normal birth
a reality: Consensus statement from the Maternity Care
Working Party. London, United Kingdom: Maternity
Care Working Party.
Mbah, A. K., Kornosky, J. L., Kristensen, S., August, E. M., Alio,
A. P., Marty, P. J., . . . Salihu, H. M. (2010). Super-obesity
and risk for early and late pre-eclampsia. British Journal
of Obstetrics and Gynaecology, 117(8), 997–1004. http://
dx.doi.org/10.1111/j.1471-0528.2010.02593.x
Miller, S., & Skinner, J. (2012). Are first-time mothers who
plan home birth more likely to receive evidence-based
care? A comparative study of home and hospital care
provided by the same midwives. Birth, 39(2), 135–144.
http://dx.doi.org/10.1111/j.1523-536X.2012.00534.x
Mozurkewich, E., Chilimigras, J., Koepke, E., Keeton, K., &
King, V. (2009). Indications for induction of labour: A
best-evidence review. British Journal of Obstetrics and
Gynaecology, 116(5), 626–636.
NSW Department of Health. (2010). Maternity—Towards
normal birth in NSW. A woman friendly birth initiative:
Protecting, promoting and supporting normal birth. Syd-
ney, Australia: Author.
Page, L. (2008). Being a midwife to midwifery: Transforming
midwifery services. In K. Fahy, M. Foureur, & C. Hastie
(Eds.), Birth territory and midwifery guardianship: The-
ory for practice, education and research (pp. 115–129).
Edinburgh, Scotland: Butterworth Heinemann.
Pickering, R. P., Grant, B. F., Chou, S. P., & Compton, W. M.
(2007). Are overweight, obesity, and extreme obesity
associated with psychopathology? Results from the
national epidemiologic survey on alcohol and related
conditions. The Journal of Clinical Psychiatry, 68(7),
998–1009.
Poobalan, A., Aucott, L., Gurung, T., Smith, W., & Bhattacha-
rya, S. (2009). Obesity as an independent risk factor for
elective and emergency caesarean delivery in nullipa-
rous women—Systematic review and meta-analysis of
cohort studies. Obesity Reviews, 10, 28–35.
Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D.
(2013). Midwife-led continuity models versus other
models of care for childbearing women. Cochrane
Database of Systematic Reviews, (8), CD004667. http://
dx.doi.org/10.1002/14651858.CD004667.pub3
Schempf, A. H., & Strobino, D. M. (2009). Drug use and
limited prenatal care: An examination of responsible
barriers. American Journal of Obstetrics and Gynecology,
200(4), 412.e411–412.e10. http://dx.doi.org/10.1016/j.
ajog.2008.10.055
Sebire, N. J., Jolly, M., Harris, J. P., Wadsworth, J., Joffe, M.,
Beard, R. W., . . . Robinson, S. (2001). Maternal obesity
and pregnancy outcome: A study of 287,213 pregnan-
cies in London. International Journal of Obesity and
Related Metabolic Disorders: Journal of the International
Association for the Study of Obesity, 25(8), 1175–1182.
http://dx.doi.org/10.1038/sj.ijo.0801670
Slavin, V., & Fenwick, J. (2012). Use of a Classification tool
to determine groups of women that contribute to the
cesarean section rate: Establishing a baseline for clinical
decision making and quality improvement. International
Journal of Childbirth, 2(2), 85.
Slavin, V., Fenwick, J., & Gamble, J. (2013). Pregnancy care
and birth outcomes for women with moderate to super-
extreme obesity. Women and Birth, 26(3), 179–184.
Stivanello, E., Knight, M., Dallolio, L., Frammartino, B., Rizzo,
N., & Fantini, M. P. (2010). Peripartum hysterectomy
and cesarean delivery: A population-based study. Acta
Obstetricia et Gynecologica Scandinavica, 89(3), 321–327.
Turnbull, D., Baghurst, P., Collins, C., Cornwell, C., Nixon, A.,
Donnelan-Fernandez, R., & Antoniou, G. (2009). An
evaluation of Midwifery Group Practice. Part I: Clini-
cal effectiveness. Women and Birth, 22(1), 3–9. http://
dx.doi.org/10.1016/j.wombi.2008.10.001
Ursavas, A., Karadag, M., Nalci, N., Ercan, I., & Gozu, R. O.
(2008). Self-reported snoring, maternal obesity and neck
circumference as risk factors for pregnancy-induced
hypertension and preeclampsia. Respiration, 76(1), 33.
Usha Kiran, T. S., Hemmadi, S., Bethel, J., & Evans, J.
(2005). Outcome of pregnancy in a woman with an
increased body mass index. British Journal of Obstetrics

and Gynaecology, 112(6), 768–772. http://dx.doi.org/
10.1111/j.1471-0528.2004.00546.x
World Health Organization. (2000). Obesity: Preventing and
managing the global epidemic (WHO Tech. Rep. Series
894). Geneva, Switzerland: Author.
World Health Organization. (2012). Controlling the global
obesity epidemic. Retrieved from: http://www.who.int/
nutrition/topics/obesity/en/
Correspondence regarding this article should be directed
to Valerie J. Slavin, RM, M Adv Prac (HC Research), BSc
Mid, Dip HE Mid, 45 Harmsworth Road, Pacific Pines,
Queensland, 4211, Australia. E-mail: val.slavin@bigpond.com
Obese Primiparous Women  Slavin et al.  129
Valerie J. Slavin, RM, M Adv Prac (HC Research), BSc Mid,
Dip HE Mid, School of Nursing and Midwifery and Mater-
nity and Family Unit, Centre for Health Practice Innovation
(HPI), Griffith Health Institute, Griffith University, and
Queensland Health Gold Coast Hospital.
Jennifer Fenwick, RM, PhD, School of Nursing and Mid-
wifery and Maternity and Family Unit, Centre for Health
Practice Innovation (HPI), Griffith Health Institute, Griffith
University, and Queensland Health Gold Coast Hospital.
Jenny Gamble, RM, PhD, School of Nursing and Midwifery
and Maternity and Family Unit, Centre for Health Practice
Innovation (HPI), Griffith Health Institute, Griffith University.
NEWS
Midwives: Changing the World One
Family at a Time
This year, the International Day of the Midwife (IDM)
once again highlighted the importance of midwives,
their work on a local and global level, and the impact
they have on families around the world. The 2014 sub-
theme “Midwives: changing the world one family at a
time” was accompanied by the overarching theme “The
world needs midwives now more than ever” as part of
an ongoing campaign to highlight the need for mid-
wives in the run-up to the deadlines for the Millennium
Development Goals (MDGs). The two themes, along
with “Midwives save lives” and “Investing in midwives,”
formed the basis of the key messages of the 2014 IDM
campaign. These key messages were presented to mid-
wives and member associations, governments, policy
makers, and other stakeholders to reinforce the themes
and provide further explanation and understanding.
An example of these messages was that midwives
change the world by caring for mothers and babies. By
caring for them, midwives help ensure that women are
healthy, thus contributing to a strong community and
economy. Moreover, midwives educate families on how
to delay, space, or limit pregnancies and provide family
planning services to achieve the healthiest outcomes
for women, newborns, infants, and children. Another
important message is that up to two-thirds of maternal
deaths could be averted if there was universal access
to a well-educated, regulated midwifery workforce in
a health system with adequate supplies. Investing in
midwives can save millions of lives every year, leading to
healthy and wealthy nations around the world.
The IDM was an opportunity to yet again raise
awareness for midwives and midwifery globally and to
INTERNATIONAL JOURNAL OF CHILDBIRTH Volume 4, Issue 2, 2014
© 2014 Springer Publishing Company, LLC www.springerpub.com
130
celebrate the truly lifesaving work midwives do. It was
an opportunity to reach out to policy makers, govern-
ments, civil society, and other stakeholders and inform
them about the benefits of quality midwifery care for
women and their children. To guide them in this advo-
cacy and organize events to showcase midwifery, Inter-
national Confederation of Midwives (ICM)’s Member
Associations were provided with a resource pack. This
pack included key messages, facts and figures, tips on
media engagement and writing a press release, a social
media guide, and the IDM artwork for posters and
use on social media. The virtual side of the IDM cam-
paign included blog series and guest blogs with partner
organizations, such as Healthy Newborn Network (an
initiative of Save the Children’s Saving Newborn Lives),
World Vision, Jhpiego (Maternal and Child Health Inte-
grated Program), and African Medical and Research
Foundation. In addition, ICM organized a global Twit-
ter chat on May 5, in which partners were matched with
member associations for a more interactive and enrich-
ing Twitter session.
Midwifery Development in China
To address the issue of midwifery development in
China, ICM organized a workshop focused on gap
analysis in Shijiazhuang, on March 25–27, 2014. The
purpose of the workshop was to contribute to the devel-
opment of midwifery in China; to learn about the situa-
tion of midwifery in China with specific attention to the
three pillars—education, regulation, and association;
and to discuss the impact of how well-resourced and
regulated midwives can contribute toward the r­ eduction
of maternal and neonatal deaths. New gap analysis tools
http://dx.doi.org/10.1891/2156-5287.4.2.130

were developed in 2012 to identify gaps and challenges
in midwifery and therefore help strengthen member
associations’ ability (in collaboration with local stake-
holders) to address the gaps. The set of documents in
ICM’s three official languages (English, French, and
Spanish) includes Member Association Capacity Assess-
ment Tool, Pre-Service Education Assessment Tool, and
Regulation Assessment Tool. They can all be found on
ICM’s website.1 The main objectives of the workshop
were to share the results of the survey conducted in
August 2013, to discuss how those results can contribute
to the recognition of midwifery profession as an autono-
mous and distinct profession, and to strengthen the
three pillars of midwifery to enable provision of quality
care to mothers and newborns in China. The workshop
provided in-depth understanding about the importance
of midwifery care for policy makers and stakeholders in
the country. To conclude the workshop and have par-
ticipants and stakeholders commit to the agreements, a
joint declaration was issued and closing remarks were
made by ICM Board Member Sue Bree.
The ICM gap analysis workshop was the first
of its kind in China. Midwifery, as an indispensable
workforce for maternal and newborn health, has gained
more support and understanding only over the past
two decades, even though the profession has existed for
centuries. Through United Nations Population Fund
(UNFPA) and 29 other international organizations and
institutions, United Nations (UN) recently appealed
for global actions to scale up midwifery care. For these
reasons, the workshop for midwifery development in
China was both internationally and domestically signifi-
cant. The development of midwifery care also provides
an answer to the country’s health care reforms under its
rapid economic, social, and technological development.
During the same week, ICM convened a 2-day
“Helping Mothers Survive Bleeding After Birth” (HMS-
BAB) workshop. This activity was part of a scientific
conference on perinatal medicine organized by Shiji-
azhuang Maternal and Child Health Hospital. Since May
2013, ICM has been working with Laerdal Global Health
and Jhpiego in disseminating the HMS-BAB initiative,
an evidence-based training program to equip midwives
with additional skills on how to manage and control
postpartum hemorrhage (PPH). The approach uses an
innovative birth simulator called Mama Natalie. Man-
agement of PPH is part of ICM’s Essential Competen-
cies for Basic Midwifery Practice2 because PPH remains
one of the leading causes of death for women and their
newborns. The HMS-BAB workshop was attended by
18 participants, who were awarded certificates for their
News  131
achievements. In a second step, these participants could
become master trainers, who in turn can train midwives
in management of PPH with HMS-BAB.
Second Middle East and North Africa
Regional Midwifery Conference,
Midwifery Education: Challenges and
Opportunities
Representatives from ICM attended the second Middle
East and North Africa (MENA) Regional Midwifery
Conference, which took place in Riyadh, Saudi Arabia,
on April 1–2, 2014. In partnership with the Minis-
try of Health, Kingdom of Saudi Arabia, the UNFPA
Arab States Regional Office committed to sustain the
momentum from the first MENA Midwifery confer-
ence in Dubai, in November 2012, by organizing this
second symposium. Midwifery education was the focus
of this 2-day conference, which explored the different
components of midwifery education, including suc-
cessful experiences and lessons learned in the MENA
countries. A main objective was to identify challenges
and the required approaches to upscale midwifery
education programmes, as well as strategies within the
region. More than 75 participants from 20 countries
attended the conference, including UNFPA staff, rep-
resentatives from World Health Organization (WHO),
United Nations Children’s Fund (UNICEF), and ICM
delegates.
One panel, titled “The Midwife: A Professional
Identity in Need to be Clarified in the Arab Region,” was
moderated by Frances Day-Stirk, ICM president. The
president also presented the Essential Competencies for
Basic Midwifery Practice,3 which answers the questions
“What is a midwife expected to know?” and “What does
a midwife do?” The competencies are evidence-based
and the majority are considered to be core or expected
outcomes of midwifery preservice education.
This document can be used by midwives, mid-
wifery associations, and regulatory bodies responsible
for the education and practice of midwifery in their
country or region. The essential competencies are
guidelines for the mandatory content of midwifery
education curricula and information for governments
and other policy bodies that need to understand the
contribution that midwives can make to the health care
system. The Essential Competencies for Basic Mid-
wifery Practice is complemented by ICM standards and
guidelines related to midwifery education, regulation,
and clinical practice.4
132 News
ICM Prague 2014: Midwives Improving
Women’s Health Globally
ICM’s 30th Triennial Congress took place on June 1–5,
2014, in Prague, Czech Republic. It was one of the larg-
est congresses in the history of ICM, attracting more
than 3,500 participants from all around the world. The
overall theme of the Congress was “Midwives: Improv-
ing Women’s Health Globally.” Key challenges facing
midwives and maternity services around the world
were addressed, recognizing the impact of the MDGs
on the work of midwives and the health of childbearing
women. Daily plenary sessions with keynote speak-
ers, partner panels, oral presentations, workshops, and
symposia, were all accommodated around the four sub-
themes of the Congress:
1. Bridging midwifery and women’s health rights
2. Access: bridging the gap to improving care and out-
comes for women and their families
3. Education: the bridge to midwifery and women’s
autonomy
4. Midwifery bridging culture and practice
The Congress has set a new record for the highest
country representation, with 1,360 abstracts received
from midwives in 85 countries. The ICM Scientific
Professional Programme Committee set the criteria for
abstract scoring and accepted 650 abstracts for presenta-
tion at the Congress.
Another highlight of the Congress was the offi-
cial appointment of Her Excellency Toyin Saraki as
ICM’s Inaugural Goodwill Ambassador. In her role as
the ICM Global Goodwill Ambassador, Mrs. Saraki
will help raise awareness of midwives and midwifery,
extending the influence of midwives, while lobbying
and advocating for policy changes relating to maternal,
newborn, and reproductive health care nationally and
internationally. She will also promote the aims, objec-
tives, and priorities of ICM and assist in facilitating
its work with member associations, especially in the
countries where maternal health is most at risk. Her
Excellency Toyin Saraki presented a keynote address at
the ICM Congress.
ICM organized several workshops during Con-
gress which focused on developing and strength-
ening midwives associations, implementing ICM
regulation standards, HMS-BAB, and Helping Babies
Breathe (HBB), as well as workshops on the Twinning
approach.5 ICM Standing Committees organized three
concurrent workshops on regulation, education, and
research. Plenary sessions were live streamed, which
was an opportunity to follow the Congress for those
unable to attend it. Daily updates on the ICM website,
Tweeting, as well as a daily newsletter kept the audience
informed and able to follow Congress events as they
unfolded.
The ICM 30th Triennial Congress provided an
excellent opportunity to share excellence in practice and
knowledge, learn about the challenges facing midwifery
across the continents, enjoy mutual support amongst
colleagues, and celebrate midwifery as a profession in
all its global diversity. It also provided an environment
where midwives from around the world could draw on
the skills, knowledge, and experience of colleagues for
application in their own countries.
A huge success was also the launch of the State
of the World’s Midwifery (SoWMy). SoWMy 2014,
the second of its kind, was a joint effort coordi-
nated by UNFPA, WHO, on behalf of the H41 (Joint
United Nations Programme on HIV/AIDS [UNAIDS],
UNFPA, UNICEF, UN Women, WHO, and the World
Bank), and the ICM to describe the state of the mid-
wifery workforce, including its challenges and pro-
gresses. SoWMy 2014 shows what progress was made
since the launch of the first report in 2011 in increas-
ing the number of skilled and competent midwives;
improving policies and regulations; and expanding
the coverage of midwifery services and quality of care
in the 75 countries that carry more than 95% of the
global burden of maternal, newborn, and child deaths.
It provides data on the availability, accessibility, accept-
ability, and quality of midwifery care. SoWMy 2014
also reveals service gaps and highlights the needs for
future health workforce and health systems to ensure
that all women and families have access to quality mid-
wifery care.
NOTES
1. http://www.internationalmidwives.org/what-we-do/
global-standards-competencies-and-tools.html
2. http://www.internationalmidwives.org/
core-documents
3. http://www.internationalmidwives.org/
what-we-do/education-coredocuments/
essential-competencies-basic-midwifery-practice/
4. http://www.internationalmidwives.org/what-we-do/
global-standards-competencies-and-tools.html
5. http://www.internationalmidwives.org/projects-
programmes/icm-interventions/twinning.html
Author Guidelines
The International Journal of Childbirth is a quarterly, peer-reviewed publication with a global focus on childbearing.
The journal invites the submission of manuscripts that address research, practice, education, and theory as well as case
reports, personal narratives, and commentaries on all aspects of childbirth.

The following presentation style should be observed when submitting manuscripts:

• Clinical and Basic Science Research articles should include an Abstract, Introduction, Material and Methods,
Case History (if applicable), Results, Discussion, Conclusion, and References.
• Review articles should provide a comprehensive synthesis of the available information on their chosen topic.
They must include headings and reference citations.
• Case Reports should be brief reviews of either typical or atypical births and should include an Abstract,
Introduction, Case Report data and findings, Discussion, Conclusion, and References.
• Personal Narratives should first-hand accounts of childbirth experiences. References are not required but may be
included when needed to support data or quotations from published sources.

Manuscript Preparation
The manuscripts should be prepared in accordance with the Publication Manual of the American Psychological
Association, which should be consulted for matter of style and formatting, including text, references, and tables.

Length. Submissions are generally expected to be 15 to 25 pages in length; however, the journal considers manuscripts
that are longer or shorter.

Cover Page. A cover page separate from the main manuscript must include the article’s title and the names, academic
degrees, mailing addresses, and e-mail addresses of each of the contributing authors.

Abstract. Research articles, review articles, and case reports should include an abstract of between 125 to 200 words
that concisely states the article’s purpose, the study design, major findings, and main conclusion.

Summary. When an abstract is not appropriate for the type of article submitted, authors should include a summary of
between 125 to 200 words that provides a synopsis of the article’s thesis and conclusions.

Appendices. Instruments or large tables of data may be included as an appendix to the manuscript. The publication
of appendices is at the discretion of the editors.

Letters to the Editor. Letters to the editor should be concise comments regarding articles published in the journal and
may include references. Letters should be under 300 words. Those accepted for publication may be edited or abridged.

Photographs, Drawings, and Graphs. Illustrations should be submitted as individual, high resolution images in jpg,
tiff, or eps graphics file formats (graphs created in Excel are also acceptable). Digital images should include the figure
number in the file name. Additionally, a copy of each illustration should be embedded at the end of the manuscript
after the reference list and tables.

Submission
Authors should submit manuscripts electronically at www.editorialmanager.com/ijcbirth

Copyright Agreement
The following dated agreement signed by all authors must accompany each manuscript submitted for publication:

The undersigned author(s) transfers all copyright ownership of the article entitled [insert the title of your article]
to the Springer Publishing Company, LLC, in the event that the article is published in the International Journal of
Childbirth. This transfer of copyright includes, but is not limited to, the worldwide rights to any and all forms of
publication now known or hereafter developed, including all forms of print and electronic media. The undersigned
author(s) warrants and represents that the article is original, is not under consideration by another journal, has not been
published previously, and contains no matter that is libelous, unlawful, or that infringes upon another copyright.
 Volume 4, Number 2, 2014
ISSN 2156-5287

International
Journal of
Childbirth
Official Publication of the International Confederation of Midwives

www.springerpub.com/ijc