How to Boost Positive Childbirth Experience in African Women

 

By: Dr. Azuka Ezeike, MBBS, FWACS (Obstetrics and Gynaecology), MSc (Public Health), Freelance Medical Writer. Editorial and Medical review by the DLHA Team.

Portrait of a black mother with positive childbirth experience holding her newborn baby and smiling lovingly. Image credit: Freepik

 

Highlights 

• A positive childbirth experience is essential for lifelong health and well-being

• Fear of mistreatment leads to avoidance of health facilities in Africa

• Common negative experiences in labour include physical and verbal abuse, neglect, and non-dignified care.

• Negative childbirth experience has immediate and delayed impacts on women

• WHO recommends respectful and dignified care, effective communication, and emotional support in labour

• Implementation of these would enable a positive childbirth experience for African women.  

 

Introduction

The experience of childbirth, whether positive or negative remains with a woman for life. When a woman goes through a difficult and negative childbirth experience, it influences her reproductive health decisions in the years to come. It also influences the health-seeking behaviour of those around her. Most times emphasis is placed on the outcome of labour with limited attention paid to the process and its consequences.

A positive childbirth experience is based on the premise that every woman deserves high-quality care in labour.[1]

The World Health Organization defines a positive childbirth experience as one that fulfils or exceeds a woman’s prior personal and sociocultural beliefs and expectations, including giving birth to a healthy baby in a clinically and psychologically safe environment with continuity of practical and emotional support from a birth companion(s) and kind, technically competent clinical staff. The childbirth process should make a woman feel safe, comfortable and positive. 

Too many interventions, poorly timed interventions, and poor attention to a woman’s emotional and psychological needs are some of the factors that lead to negative childbirth experiences. [2]

According to data from the World Bank Group, the average percentage of births by skilled birth attendants in sub-Saharan Africa as of 2019 was 64%. Countries like South Sudan have values as low as 19%. This is also corroborated by data from the World Health Organization (WHO)

The low figures are not just because of a lack of availability of healthcare facilities but also as a result of unwillingness to access maternity care at health facilities because of fear. It is typical in rural Africa to see a woman deliver at home or in a traditional birthing place. This is not usually because of a lack of access but because of fear of mistreatment. [3]

It is not just enough to provide skilled birth attendance. To reduce maternal deaths, skilled attendance should be provided in a respectful and humane environment. [4]

A positive childbirth experience is crucial in building a woman's self-esteem and self-efficacy. [5] Ultimately it leads to greater access to health care for the mothers and their families.

The objectives of this article are to:

• Give an overview of the current state of childbirth practice in Africa
• Provide insight into the negative childbirth experiences of women and their consequences
• Discuss the WHO recommendations for ensuring a positive childbirth experience
• Describe the measures and metrics for the assessment of a  positive childbirth experience

 

Understanding the Current Childbirth Experience in Africa

In rural Africa, there are a lot of childbirth cultural preferences like birthing positions, herbal medications and postpartum practices. These practices influence most women to resort to delivery at home attended by relatives or at a traditional birthing home. Some of these practices have been so entrenched that even with the availability of health facilities, patronage is still low. 

Even when these births get complicated and the women are brought to the hospital, some still find it difficult to adapt to the practices at the hospital. There have been cases of rural women referred to a tertiary facility for delivery who refused to climb the delivery couch because the cultural practice in their community is to deliver on the floor. The failure of maternity centre staff to address the personal, and sociocultural beliefs and expectations of the women hinders the optimal utilization of health facilities.

A review of some studies done in sub-Saharan Africa shows that the experience of childbirth is still suboptimal in many facilities, especially public hospitals. [6]  Another study done in Ethiopia showed that only 35.8% of the women who just recently delivered received respectful care. [7] The mistreatment of women in the labour ward contributes to health inequalities as it leads to reduced use of facility-based services in low and middle-income countries. [8]

Skilled birth attendance has been recommended as a crucial tool to reduce maternal mortality that is related to labour and delivery.  However, the maternal health indices have yet to improve significantly in Africa over the years as a result of fear of facility-based care. This is occasioned by negative childbirth experiences. This would hinder the efforts towards achieving Goal 3 of the sustainable development goals. 

Negative Childbirth Experiences

Some of the negative childbirth experiences of women include:

• Physical abuse: Some women are slapped, pinched or hit on the thighs especially at the point of delivery as a way of getting them to push out the baby

• Verbal abuse: This is reported to be the most common form of abuse. It could take the form of talking to the women in raised voices or using demeaning or abusive words

• Neglect and abandonment: In some overcrowded labour wards, some patients may not be attended to on time and feel left out. The lack of companionship also contributes to the feeling of abandonment

• Non-dignified care: The failure to introduce oneself to the patient, not cleaning the patient after birth, and failure to clean the delivery bed are non-dignifying

• Non-consented care: Conducting procedures without obtaining informed consent from the women. A study done in South Africa showed that consent for physical examination was obtained in less than 50% of the women in labour. [9]

• Lack of communication: Incomplete, unclear, tardy and inconsistent information to patients and across shifts

• Discriminatory care: Some patients; especially young, uneducated women may not receive adequate attention in labour wards

• Detention in health facilities: This is due to failure to pay the hospital bills.

 

Impact of Negative Childbirth Experiences 

Negative childbirth experiences are usually due to fear-based emotions and this has immediate and remote consequences. [10, 11, 12] The impact of a negative childbirth experience includes;

Immediate Consequences

• Lack of self-esteem

• Loss of mother-infant bonding

• Inability to breastfeed

Delayed Consequences

• Lack of self-esteem

• Post-traumatic stress disorder

• Fear of childbirth

• Avoidance of pregnancies

• Delay of subsequent pregnancies

• Request for caesarean sections/abortions in subsequent pregnancies

 

Essential Components of a Positive Childbirth Experience

Enhancing a positive childbirth experience starts from the Antenatal period, Evidence shows that adequate knowledge through antenatal education instils confidence and improves the childbirth experience. [13] 

Positive childbirth experience entails the quality of care the pregnant woman in labour receives from the moment she steps into the labour room till the time she leaves the labour room with her baby. It involves the interaction between her, her relatives/companions and the maternity ward staff.

In 2018 the WHO released a guideline on labour care for a positive childbirth experience. 

The recommendation aims to shift the focus from not just achieving safe birth but also making the process a positive experience for both the women and their families. The guideline emphasises woman-centred care through a human rights-based approach. 

To further improve the childbirth experience the WHO introduced the Labour Care Guide as a tool for the implementation of the 2018 recommendations.

The World Health Organization has recommended action plans for positive childbirth experience in three domains:

• Respectful and dignified care

• Effective communication and support

• Emotional support and companionship

In addition, the WHO also made the following recommendations on modifying the management of the different stages of labour to reduce unnecessary interventions. [1]

 

What is Respectful and Dignified Care? 

The WHO defines respectful care as care organized for and provided to all women in a manner that:

• Maintains their dignity, privacy and confidentiality

• Ensures freedom from harm and mistreatment

• Enables informed choice and continuous support during labour and childbirth. 

In many facilities, mistreatment is normalised and little attention is paid to the autonomy and emotional state of the patients. This leads to the dread of the labour room for many pregnant women.

Instituting respectful maternity care at the facilities helps to reduce the mistreatment of women giving birth at the health facilities.

Respectful maternity care calls for actions to be taken at the levels of the healthcare facility, the health system, and at the interpersonal level between a woman and her healthcare providers.

Entrenching respectful maternity care will involve:

• Having an adequate number of trained and highly motivated staff. This is because bad maternity staff attitude has been linked to negative childbirth experiences

• Provision of refreshments to the health service staff to improve their morale

• Having regular in-service training of staff  and health care facility managers on respectful maternity care  and health ethics principles

• Provision of health information materials and informed consent forms in labour wards

• Having an adequate supply of essential medicines

• Provision of adequate equipment in the labour ward to enhance service delivery

• Provision of screens, curtains and partitions in the labour ward  to enhance privacy

• Provision of adequate physical space for the woman and her companion

• Provision of a clean, well-ventilated labour ward with bathroom facilities to enhance dignity

• Community engagement with the aim of including women's voices in their care

 

What is Effective Communication and Support? 

The WHO recommends effective communication between maternity care providers and women in labour, using simple and culturally acceptable methods

This involves:

• Introducing self to the woman and her companion

• Communicating with the woman in plain language that she understands, including the local language if need be

• Positively responding to the women's needs and preferences including the choice of birthing positions

• Being empathetic and showing compassion

• Not overriding the patient's choices but supporting her choice and encouraging shared decision-making

• Explaining  procedures to the woman and obtaining her consent before commencing

• Updating the woman and her companion on the progress of labour

• Continuous emotional and physical support

• Ensuring privacy and confidentiality in verbal communication

Implementing this would require:

• Having the right complement of staff with the necessary skill set

• Regular in-service training on communication skills

• Provision of health education materials

• Supervisory visits and support to clinical staff and regular review meetings

 

What is Emotional Support and Companionship?

Companionship and emotional support reduce the need for pain relief and improve the birth experience. The WHO recommends a companion of choice for all women throughout labour and childbirth.

This may be a family member of her choice or a doula (a woman who has been trained to provide labour support. Allowing companionship in labour is a cost-effective and culturally sensitive way to address the concerns of the patient.

Implementing this would require

• Orientation of labour ward staff and companions
• Accommodation facilities for companions including chairs, toilet facilities
• Facilities  to support privacy and confidentiality, including dividers/curtains
• Private physical space for the woman and her companion at the time of birth

 

Measures of Success for Positive Childbirth Experience

Success in achieving a positive childbirth experience can be measured using the following criteria:

• Patient Satisfaction Surveys

Exit surveys to gather feedback from women about their childbirth experiences, focusing on their perceptions of respect, dignity, communication, and support received during labour and delivery. This involves using a questionnaire with multiple quotations on the different domains. [14, 15] This however is a subjective form of assessment.

• Clinical Outcomes

Monitoring of clinical indicators such as maternal and neonatal morbidity and mortality rates, frequency of interventions, and rates of complications during and after childbirth.

• Utilization of Maternity Services

Negative childbirth experiences deter women from having facility-based delivery. Tracking the changes in the utilization of facility-based maternity services, including the number of women opting for skilled birth attendance and returning for postpartum care is a measure of assessment.

• Staff Attitudes

Supervisory manager’s direct observation of maternity staff attitude to patients. This helps to evaluate the effectiveness of training programs for healthcare providers on respectful maternity care principles. 

• Reports of Mistreatment

Measurement of the frequency of reported incidents of mistreatment, abuse, and neglect in labour wards 

 

 Conclusion

The lack of dignity and respect compromises the quality of maternal care. Safe motherhood would be impossible if the women who are meant to receive the interventions avoided the health facilities because of mistreatment. Ensuring a positive childbirth experience leads to improved health-seeking behaviour by the woman and her family. Ensuring the interventions in Africa has resource implications. Basic to this is the training of health workers who are the key stakeholders in the implementation.

 

References

1.  WHO recommendations: Intrapartum care for a positive childbirth experience [Internet, 2018 Feb. 7]. Cited 2024 Jul 16. Available from here.

2.  World Health Organization. Making childbirth a positive experience [Internet, n.d.]. Cited 2024 Jul 16. Available from here.

3.  Window M, Msiska MT, Nayupe SF, Lungu G. Dignity in childbirth: A perspective from sub?Saharan Africa. Public Health Challenges [Internet]. 2023 Dec, 2(4):e146. Cited 2024 Jul 13. Doi:10.1002/puh2.146. Available from here.

4.  Hosseini Tabaghdehi M, Keramat A, Kolahdozan S, Shahhosseini Z, Moosazadeh M, Motaghi Z. Positive childbirth experience: A qualitative study. Nursing Open [Internet, 2020 April 14]. Jul 7(4):1233–8. Cited 2024 Jul 13. Doi:10.1002/nop2.499. Available from here.

5.  World Health Organization Standards for improving quality of maternal and newborn care in health facilities [Internet. 2016 Jul 4]. Cited 2024 Jul 13. Available from here.

6.  Gwacham-Anisiobi U, Banke-Thomas A. Experiences of health facility childbirth in sub-Saharan Africa: a systematic review of qualitative evidence. Matern Child Health J. 2022 Mar; 26(3):481–92.  doi: 10.1007/s10995-022-03383-9. Available from here.

7.  Bulto GA, Demissie DB, Tulu AS. Respectful maternity care during labour and childbirth and associated factors among women who gave birth at health institutions in the West Shewa zone, Oromia region, Central Ethiopia. BMC Pregnancy and Childbirth. 2020 Aug 3;20(1):443.  doi: 10.1186/s12884-020-03135-z. Available from here.

8.  Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, Gülmezoglu AM. Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reproductive Health. 2014 Sep 19;11(1):71. doi: 10.1186/1742-4755-11-71. Available from here.

9.    Oosthuizen SJ, Bergh AM, Pattinson RC, Grimbeek J. It does matter where you come from: mothers’ experiences of childbirth in midwife obstetric units, Tshwane, South Africa. Reproductive Health. 2017 Nov 16;14(1):151. Doi: 10.1186/s12978-017-0411-5. Available from here.

10. Viirman F, Hess Engström A, Sjömark J, Hesselman S, Sundström Poromaa I, Ljungman L, et al. Negative childbirth experience in relation to mode of birth and events during labour: A mixed methods study. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2023 Mar 1;282:146–54. Available from here.

11. Shiva L, Desai G, Satyanarayana VA, Venkataram P, Chandra PS. Negative childbirth experience and post-traumatic stress disorder - a study among postpartum women in south India. Front Psychiatry. 2021 Jul 6;12:640014. doi: 10.3389/fpsyt.2021.640014. Available from here.

12. Shorey S, Yang YY, Ang E. The impact of negative childbirth experience on future reproductive decisions: A quantitative systematic review. J Adv Nurs. 2018 Jun;74(6):1236–44. doi: 10.1111/jan.13534. Available from here.

13. Crowe K, Von Baeyer C. Predictors of a positive childbirth experience. Birth 1989 Jun;16(2):59–63. doi: 10.1111/j.1523-536X.1989.tb00862.x. Available from here.

14. Konieczka J, Tomczyk K, Wilczak M, Chmaj-Wierzchowska K. Factors affecting women’s assessment and satisfaction with their childbirth. Medicina. 2024];60(1):86. doi: 10.3390/medicina60010086. Available from here.

15. Dencker A, Taft C, Bergqvist L, Lilja H, Berg M. Childbirth experience questionnaire (CEQ): Development and evaluation of a multidimensional instrument. BMC Pregnancy and Childbirth [Internet]. 2010 Dec 10 [cited 2024 Jul 18];10(1):81. Doi: 10.1186/1471-2393-10-81. Available from here.

 

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Published: June 22, 2024

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