Nordic Homebirth Research Group consisting of Ellen Blix, PhD, is a principal curator, TromsÖ, University Hospital, Norway; Hanne Kjaergaard, PhD, is a clinical associate professor, Juliane Marie Research Centre, Denmark; OlofAsta Olofsdottir, PhD, is a professor, Reykjavik University, Iceland; Ingegerd Hildingsson, PhD, is a professor, Mid-Sweden University, Sweden; Li Thies-Lagergren, PhD, is a clinical midwife, Helsingborg General Hospital, Sweden; Ingela Radestad, PhD, is a professor, Sophiahemmet University College, Sweden; Ingela Lundgren, PhD, is an associate professor, The Sahlgrenska Academy, University of Gothenburg, Sweden
Creating a Safe Haven—Women's Experiences of the Midwife's Professional Skills During Planned Home Birth in Four Nordic Countries
Article first published online: 21 MAR 2014
© 2014, Copyright the Authors Journal compilation © 2014, Wiley Periodicals, Inc.
Volume 41, Issue 1, pages 100–107, March 2014
How to Cite
Birth 41:1 March 2014
- Issue published online: 21 MAR 2014
- Article first published online: 21 MAR 2014
- Manuscript Accepted: 12 NOV 2013
- home birth;
- mixed method;
- professional skills;
- women's experience
The midwife assisting a birth has a considerable influence on the woman's experience of the birth. The aim of this study was to investigate the experience of the midwife's professional skills among women in Norway, Denmark, Iceland, and Sweden who chose a planned home birth.
Design and Setting
All known home birth midwives were asked to inform the mothers about the project and invite them to complete a questionnaire about different aspects of their home birth experience.
The women were asked to assess 10 different aspects of the midwives' professional skills on a 4-graded scale below the main question: What was your experience of the midwife who assisted the labor? Furthermore, the mothers' experiences with the attending midwives were identified in the free text birth stories. The chosen method was a mixed method design.
The home birth midwives' professional skills were generally high scored. No statistically significant differences were found with respect to the assessment of the midwife. The content analyses yielded one overarching theme: The competence and presence of the midwife creates a safe haven, and three categories, midwife's safe hand, midwife's caring approach, and midwife's peaceful presence.
Women choosing a home birth in the four Nordic countries experienced that their midwives were highly skilled and they found the presence of the midwives valuable in helping them to feel safe and confident during birth. Despite differences in organization and guidelines for home births, the women's experience of the midwife's professional skills did not differ between the four countries.
In four of the Nordic countries, Norway, Denmark, Iceland, and Sweden, the culture and linguistic context, public health conditions, and the health care system with tax-paid equal access for all habitants are rather similar. Furthermore, maternity care is free of charge and midwives are the primary caregivers in normal pregnancy and childbirth. The prevalence of home births for Sweden and Norway is about one per thousand and for Denmark and Iceland 1–2 percent [1-6]. In national registers, home births are sometimes missing because of misclassification or absence of reporting . The Nordic countries differ with respect to the regulations for women opting for a home birth. In Denmark, women have the right to be attended by a midwife during a home birth, national guidelines are available, and the home birth service is funded by taxes . In Norway and Iceland, the service is fully or partly funded by taxes and national guidelines are available [8, 9], but access to a midwife attending the birth varies geographically. In the Stockholm County Council, guidelines have been developed for publicly funding planned home births; for the rest of Sweden (25 councils), no guidelines have been formulated, and the woman who wishes to give birth at home must pay for what is purely a private service . In the Nordic countries, midwives usually work either in prenatal care or in the delivery ward, and women who give birth in the hospital are randomly assigned to the midwife available at the moment. Women who give birth at home usually see the assisting midwife during pregnancy. Planned home births are associated with a high incidence of spontaneous vaginal birth with few interventions [5, 11, 12] and a high degree of satisfaction [13-15]. The nature of the relationship with the midwife is fundamental in determining satisfaction with the experience of childbirth and the medical outcome as well [16-21]. Having a negative experience with the midwife increases the risk for the overall birth experience to be negative [22, 23]. For women who choose a home birth, the contact with the midwife is usually established during the pregnancy and is mentioned as one of the reasons for choosing a home birth [14, 24]. Other reasons are the increased autonomy, considering the birth as a natural process, and the ability to have the family around [14, 15, 24]. As the role of the midwife is important for a positive birth experience and the degree of satisfaction with home birth is high, it could be presumed that the midwife in attendance in the home birth setting possesses certain qualities and skills, others than those attending in hospital. Midwives explain how they use a different approach when assisting at home than in the hospital [25-27]. Up to the present time, little is known about how mothers view the midwives who assist home births in the four Nordic countries and if the perception of them is influenced by the organization of home births. The aim of this study was to investigate the experience of the midwife's professional skills among women in Norway, Denmark, Iceland, and Sweden who chose a planned home birth.
This population-based, multinational study is inspired by a mixed method design, used when a question can be answered from both quantitative and qualitative data, and the results can give convergence to each other . In this study, a concurrent triangulation approach is used; the quantitative and qualitative data collection is concurrent and there is no predominance of the qualitative or quantitative data. The questions used are taken from a questionnaire using assessment scales and open-ended questions. The analyses were done separately and the results presented side-by-side, integrated with the answers from both types of analysis . The study was approved by the Regional Research Ethics Committee of Karolinska Institutet in Stockholm, Sweden, nr 2009/147-31.
Setting, Sample, Data Collection
A collaborative research project among Sweden, Denmark, Iceland, and Norway was established in 2009 with the aim of enhancing the knowledge about planned home births in the four countries. A study-specific web questionnaire (available at www.nordichomebirth.com) was developed based on a previously used questionnaire from a similar project [13, 29]. The questionnaire was tested by face-to-face validity with eight women. The concepts used for describing the midwives' competence are in accordance with what is known to be significant in the midwife–woman relationship . The questionnaire was translated into each of the Nordic languages. All known home birth midwives were asked to inform the mothers with a planned home birth about the project and ask them to fill out the questionnaire. In this study, planned home birth means births planned to occur at home that started spontaneously at home, irrespective of whether the woman was transferred to hospital during labor or after birth. The data analyzed in this study were drawn from the register September 1, 2011. The women were asked to assess the midwives' professional skills on a 4-graded Likert scale. Ten different aspects of the midwives' qualities were estimated below the main question: What was your experience of the midwife who assisted the birth? Statements were assessed using the four options: Not agree at all, disagree partly, agree partly, and agree completely (Table 2).
The software program SPSS 20.0 (IBM Corp., Chicago, IL, USA) was used for the descriptive analysis and Pearson's chi-square test was performed to detect potential differences between the countries. As the responses tended to be extreme toward either the negative or positive end of the scale, the cutoff point was set between agree completely and the other three alternatives (i.e., 1–4).
A qualitative approach was used to further explore the women's experience with the midwife . The women responded to one open question where no limit was placed on the length of the response. The question was: “Could you please describe the birth in your own words?” A qualitative content analysis was used to analyze the birth stories to find descriptions of the midwife assisting their home birth. All the birth stories were read through in a naïve reading and meaning units containing any information about the midwife were identified. All units were read through several times to get a sense of the content and the meaning units were then condensed and subcategories created on basis of differences and similarities. Finally, categories were created related to the content with respect to the experience of the midwives. The two authors (IS and HL) discussed the meaning units, subcategories, and categories. In a final step reflection within the research group resulted in one overarching theme. During the whole analysis process the intention was to stay as close to the written texts as possible by moving frequently from the whole to the parts and from the parts to the whole .
A total of 939 women answered the questionnaire. The distribution among the countries is shown in Table 1. The age of the women ranged from 19 to 42 years with an average of 34 years. No statistically significant differences were found between the countries with respect to sociodemographic factors. The overall transfer rate in this sample was 12.5 percent. The result shows a high level of satisfaction regarding the different aspects of the midwife's skills (Table 2). For the majority of the questions, around 90 percent of the women responded that they fully agreed with the statements describing the midwife as competent. Concerning the midwives’ attention to the partners' needs, about three of four women fully agreed. No statistically significant difference between the countries was identified. Overall, 3 percent of the women responded that they did disagree to statements describing the midwife as competent, but no statistically significant differences were detected between the countries.
|Variable||Sweden N = 137 No. (%)||Denmark N = 719 No. (%)||Norway N = 36 No. (%)||Iceland N = 47 No. (%)|
|<25 yr||7 (5)||32 (4)||5 (14)||12 (26)|
|25–29 yr||32 (23)||201 (201)||13 (36)||18 (38)|
|30–34 yr||75 (55)||342 (48)||12 (33)||10 (21)|
|35+ yr||23 (17)||142 (20)||8 (22)||7 (15)|
|Married/cohabitating||126 (92)||632 (88)||32 (89)||42 (89)|
|Single/Other||11 (8)||87 (12)||4 (11)||5 (11)|
|Elementary school||5 (4)||42 (6)||3 (8)||3 (6)|
|High school||21 (15)||83 (12)||10 (28)||12 (26)|
|University 1–3 yr||72 (53)||351 (49)||18 (50)||21 (45)|
|University >3 yr||38 (28)||243 (34)||15 (42)||11 (23)|
|First child||9 (7)||167 (23)||8 (22)||12 (26)|
|2–3rd child||113 (82)||418 (58)||20 (56)||31 (66)|
|4th child or more||15 (11)||134 (19)||8 (22)||4 (9)|
|Question: How did you experience your midwife who was present during the birth? I think she was:||Sweden N = 120 No. (%)||Denmark N = 719 No. (%)||Norway N = 36 No. (%)||Iceland N = 47 No. (%)|
|Fully agree||102 (92)||643 (93)||31 (97%)||46 (98)|
|Do not fully agree||8 (8)||50 (7)||1 (3%)||1 (2)|
|Fully agree||95 (89)||641 (93)||30 (94)||42 (89)|
|Do not fully agree||12 (11)||51 (7)||2 (6)||5 (11)|
|Fully agree||101 (92)||630 (91)||29 (91)||41 (89)|
|Do not fully agree||9 (8)||60 (9)||3 (9)||5 (11)|
|Fully agree||100 (91)||644 (93)||32 (89)||46 (98)|
|Do not fully agree||10 (9)||48 (7)||4 (11)||1 (2)|
|Fully agree||96 (87)||639 (92)||32 (100)||45 (96)|
|Do not fully agree||14 (13)||56 (8)||0||2 (4)|
|Fully agree||99 (90)||658 (94)||32 (100)||46 (98)|
|Do not fully agree||11 (10)||40 (6)||0||1 (2)|
|Fully agree||100 (91)||632 (91)||32 (100)||43 (93)|
|Do not fully agree||10 (11)||62 (9)||0||3 (7)|
|Attentive to my needs|
|Fully agree||97 (88)||632 (90)||32 (100)||43 (91)|
|Do not fully agree||13 (12)||68 (10)||0||4 (9)|
|Attentive to partners' needs|
|Fully agree||88 (81)||563 (82)||27 (84)||36 (78)|
|Do not fully agree||21 (19)||127 (18)||5 (16)||10 (22)|
Altogether, 603 women had written down their birth stories in response to the open question. A total of 355 (59%) of the birth stories included statements about the midwife. The greatest number of responses was from Denmark (n = 293), and then, in descending order, Sweden (n = 58), Iceland (n = 16), and Norway (n = 16). The extent of the birth stories varied from a few words to detailed descriptions from onset of labor until some hours after the birth. The content analysis resulted in one general theme: The competence and presence of the midwife create a safe haven, strengthened by the woman–midwife relationship created during the pregnancy. The theme illustrates the interpreted meaning of the women's experience of the midwife as being physically, emotionally, and mentally present to the fullest extent. This gesture strengthened the women's feelings of safety and comfort and allowed them to give birth on their own terms following their own rhythm. Knowing the midwife was an important part of feeling safe, as the mother didn't have to explain or express her feelings and wishes. Some women who did not know their midwife mentioned it as something they missed, whereas others said it did not matter, as the midwife easily created a good relationship with the parents. Three categories: midwife's safe hand; midwife's caring approach, and midwife's peaceful presence, with subcategories, were identified and are presented integrated with the results from the statistical analysis concerning midwives’ competence (Table 3).
|Overall theme. The competence and presence of the midwife creates a safe haven strengthened by the woman-midwife relationship created during the pregnancy.|
|Midwife's safe hand/medical and technical skills and confidence||Midwife's caring approach/supportive, encouraging, and emotionally skilled||Midwife's peaceful presence/calm, worshipful, attentive to my needs|
|Having control over the course||Provide support/encourage||Showing respect by staying in the background|
|Having sense of when and how action is needed||Guidance||Create peace and security|
Midwife's Safe Hand
The women reported that the midwife had an overview of the birth process and was able to grasp the situation, which made them feel safe. The results correspond well with assessments of medical skills where overall 95 percent of the respondents completely agreed that the midwife was medically skilled (range 93–98%), 91 percent fully agreed that she was technically skilled (range 89–94%), and 93 percent (range 91–100%) fully agreed that the midwife was confident.
Having Control Over the Course
This subcategory described midwives’ way of having a watching eye over the process, by checking the wellbeing of mother and child and that the birth was proceeding normally. She examined the newborn baby, checked that everything was fine, and if necessary supported the baby and the mother after birth.
She (midwife) listened to the fetal heart sounds and they were just fine. She said that I was completely dilated, something I had not realized (Norway).
The midwife picked up my daughter from the water and observed that she was pale (Denmark).
Having a Sense of When and How Action is Needed
The women often described the midwife as nonactive, but when needed, she was more active. She could recommend acupuncture or a bath when time was right for that. When the woman felt like she was losing control, a the midwife took a more assertive role. Some of the women were advised to go to the hospital because of slow progress of labor or having a retained placenta, and then the midwife ensured a safe transfer.
The delivery itself was a good experience but our daughter had to be suctioned, given oxygen, and stimulated (Denmark).
We felt really well taken care of (Norway).
Midwife's Caring Approach
The midwife cared for the women in a way that they said helped them through labor. It was described as a feeling of loving, caring hands and being in the total center of the attention, described as strengthening their self. This is in line with the finding from the statistical analysis showing that 95 percent of the women completely agreed with the statement that the midwife was supportive (range 89–100%), 90 percent meant that she was encouraging (range 86–94%), and 91 percent fully agreed that she was emotionally skilled (range 89–92%) (Table 2).
Provides Support and Encouragement
Many of the women carefully described the support they experienced from the midwife, perceived not only as professional but also as loving and encouraging attendance. The support could be specific, such as a focus on breathing or pressing an aching back, described in terms of cooperation, good teamwork between the woman, the partner, and the midwife. It was also encouraging to receive information about the labor progress.
The midwives supported me without at all taking over from me (Sweden).
She encouraged me and said all the right things. She helped me to experience childbirth as a natural event, and the pain as well (Iceland).
Two of the women experienced lack of support, because the midwives arrived just before the birth and no time was there to establish contact.
I didn't really manage to establish any real contact with the midwife, so … I felt a bit alone during the final hours (Denmark).
Guidance from the midwife referred to being there with ensuring and supportive words in certain situations. Specific guidance could be helping the woman, breathing and cooperation during the pushing phase, and following the sensations of the body. Lack of guidance was described as being missed if the midwife did not come in time for the birth or if not enough guidance was provided.
So nice with her safeguard presence and soft voice who guided me when the labour was most intense… like a light in the dark (Sweden).
The only thing that was missing was a bit more guidance from the midwife during that phase. I did not get to know if I was doing right or how long a time was left (Denmark).
Midwife's Peaceful Presence/Calm, Worshipful, Attentive to my Needs
The peaceful presence of the midwife was understood as an important component for the woman's feeling of safety. It was crucial for the women to know that someone with professional skills was sitting guard, keeping the process in mind. This is also mirrored by the results from the statistical analysis; 93 percent of the women fully agreed that the midwife was calm (range 90–100%), 95 percent (range 90–100%) that she was worshipful, and 92 percent agreed to the statement that she was attentive to the woman's needs (range 88–100%). (Table 2).
Showing Respect by Staying in the Background
For some women, it was important to stay in control of the situation and they did not want anybody to take over and tell them what and how to do, but listen to their own bodies and follow the process. With the midwife in the background they felt free to do this. The midwife was perceived as a guest in the woman's home and it was significant that she also acted like one. To be treated with respect was described by the women as being taken seriously.
The midwife had complete confidence in me and was there keeping her distance in the background (Sweden).
Really great midwife who was good at listening to our wishes and thoughts (Denmark).
Four women reported that the midwife did not fully respect their wishes and needs, which made their birth experience not what they had expected.
I had requested a natural third stage with the cord intact … but she repeatedly asked if she could cut the cord, despite my wishes (Sweden).
Everything went according to plan until the midwife denied that I was in the transition stage, but I felt I was—and I was (Denmark).
Create Peace and Security
The midwife was perceived as tranquil and peaceful, and her presence, more than her action, was described as creating a space of peace and security. The midwife took her time; nothing else was there to disturb her concentration of the birthing woman. Some women mentioned that they were better cared for at home than in the hospital because at home the midwife could be by the woman's side all the time.
The midwife was fantastic, my heart gets warm when I think of her… supportive, warm and incredibly safe to have her (Sweden).
She was there when I needed her, her calmness made that I didn't feel insecure at any time (Denmark).
Women with planned home births in the Norway, Denmark, Iceland, and Sweden experienced that the midwives in general were highly skilled with respect to medical and emotional aspects. The women's experiences could be understood as resulting from the midwives creating a safe haven, an environment where the women felt safe and could focus on the birth process.
Despite differences with respect to organization and guidelines between the countries, no statistically significant differences were found between the countries with respect to the factors related to the midwife's competence. Women choosing a home birth seem to be more satisfied with their birth experience than women giving birth in the hospital [31, 32]. Morison et al  and Dahlen et al  described similar findings and concluded that women planning for a home birth had clear expectations for the birth and made some efforts to get them realized. This included having a close contact to a known midwife, who provided support, and enhanced their confidence in their abilities to achieve a normal birth . However, according to the results, organization and guidelines may be of less importance when the home birth actually takes place; the midwife comes as a guest to the woman and provides woman-centered care.
The women in this study emphasized the midwives’ presence, rather than their actions. The midwives being present and fully able to observe, assess, and act when needed are highly valued characteristics that have been described previously [14, 15, 33, 34]. The presence, the “being there,” that is characterized by being seen and listened to was more important than what was said and done [13, 37, 38] and the midwife was not expected to fulfill other tasks as might be expected in a delivery ward . The concept of “being with woman” described by Hunter  is defined as presence and support, psychological, emotional, and physical, given by the midwife in accordance with the wishes of the woman giving birth related to the model of woman-centered childbirth care described by Berg et al . Three central components are described: the reciprocal relationship, the birthing atmosphere of calm, trust, and safety, and the grounded knowledge of the midwife. Presence and continuous support are shown to have considerable influence on women's ability to give birth on their own terms [36, 38, 39]. The women's experience of the concept of “being with woman” as described in this study might explain the high estimates of midwifery skills and competence.
The large number of respondents in this study strengthens the results, and we have reason to believe that a large percentage of all women who gave birth at home during the study period responded to the question. However, because of uncertainty in national birth registers, we do not know the total number of home births during the study period. We do not know how many of the midwives informed how many women, and how many informed women answered the questionnaire, but the number of respondents corresponds well with the number of births registered by the midwives in the same research project. Women who were dissatisfied may not have responded to the questionnaire, but on the other hand one could assume that those who were really dissatisfied would take the opportunity to report their experiences. As home birth rates differ between the four countries, the uneven distribution of responses from the different countries mirrors the reality. The midwives’ different skills were not defined in the questionnaire; hence, the results are based on women's subjective interpretation of each statement.
The midwives in the four countries were successively informed about the project. This explains the small number of participants from Norway where information about the project was given later than in the other countries.
The women were asked to write down their birth stories in their own words; they were not specifically asked to express their experiences of the midwife's skills. This procedure may result in lack of information, but we can assume that if the midwife was important to the birth experiences, she would be mentioned in the birth stories, as previously reported by Wilde et al  and Janssen et al .
The concurrent triangulation generally uses separate qualitative and quantitative analysis methods and the results can be integrated or connected, or used side by side to reinforce each other, often in the discussion section as in this study . The content analysis was performed by two of the authors (IS and HL) in continuous discussion with the third author (EI), and the results were reflected within the Nordic home birth group. The use of mixed method approach applied in this study proved a strength as the qualitative data helped validate the quantitative ones, to amplify and give a more personal insight into the women's experience of the home birth midwife .
Women choosing a home birth in Norway, Denmark, Iceland, and Sweden are highly satisfied with the competence of their midwives. Despite the differences in organization and guidelines for home births, the women's experience of the midwife's professional skills does not differ between the four countries. The strength of the woman–midwife relationship seemed to be similar from country to country irrespective of the nature of the health care system within the four Nordic countries. Further research about the experience of the midwives attending home birth would contribute to the body of knowledge in this field.
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