‘To be Informed and Involved’: Women's insights on optimising childbirth care in Lithuania

Abstract Introduction The user expectations and experiences of healthcare services are acknowledged as components of the quality of healthcare evaluations. The aim of the study is to analyse women's experiences and views on childbirth care in Lithuania. Methods The study used the Babies Born Better (B3) online survey as the data collection instrument. The B3 is an ongoing longitudinal international project, examining the experiences of intrapartum care and developed as part of EU‐funded COST Actions (IS0907 and IS1405). Responses to open‐ended questions about (1) the best things about the care and (2) things in childbirth care worth changing are included in the current analysis. The participants are 373 women who had given birth within 5 years in Lithuania. A deductive coding framework established by the literature review was used to analyse the qualitative data. The framework involves three main categories: (1) the service, (2) the emotional experience and (3) the individually experienced care, each further divided into subcategories. Results Reflecting the experience and views regarding the service at birthplace women wished empowerment, support for their autonomy and to be actively involved in decisions, the need for privacy, information and counselling, especially about breastfeeding. In terms of emotional experience, women highlighted the importance of comprehensibility/feeling of safety, positive manageability of various situations and possibilities for bonding with the newborn. Individually experienced care was described by feedback on specific characteristics of care providers, such as competence, personality traits, time/availability and encouragement of esteem in women in childbirth. The possibilities of homebirth were also discussed. The findings reflected salutogenic principles. Key Conclusions The findings suggest that the Lithuanian healthcare system is in a transition from paternalistic attitude‐based practices to a shift towards patient‐oriented care. Implementation of the improvements suggested for women in childbirth care in Lithuania would require some additional services, improved emotional and intrapersonal aspects of care and a more active role for women. Patient/Public Contribution Patients and the public contributed to this study by spreading information about surveys and research findings through their involvement in service user groups that have an interest in maternity care. Members of the patients' groups and the public were involved in the discussion of the results.


| INTRODUCTION
Around the world, there is a shift in the focus of health care, from survival only, to also emphasising patient-centred care, health improvement and subjective patient wellbeing. The user expectations and experiences of healthcare services are acknowledged as components of quality of care evaluations 1 and as a reflection of interactions between patients and the health system. 2 The World Health Organisation vision of quality of care for pregnant women and newborns includes a women-centred component, taking into account the preferences and aspirations of individual service users, 3 with criteria for quality evaluation involving women's experience of effective communication, respect and preservation of dignity and emotional support. 4 The current guidelines recognise that the notion of a positive experience is as critical as good clinical outcomes for babies, 5,6 based on a systematic review of what matters to women during childbirth. 7 Childbirth is a critical moment in the transition to motherhood. This transformation can be positive or stressful, as a labouring woman is simultaneously in a powerful and potentially vulnerable state, both clinically and emotionally. 8 As a complex and multidimensional experience of care, it has an impact on the future wellbeing of both mother and child. 9-11 A negative mother's perception of birth care experience is associated with postpartum anxiety and depression. 11 Postpartum depression has been linked to a reduced capacity to perceive an infant's emotions and respond adequately. 12,13 Women's accounts of their birth care experience could be a useful early indicator for later wellbeing or for potential psychological adversity. Supporting women to make informed decisions by providing information about birth setting options and variations is a critical patient-centred strategy. 14 There is strong evidence that if a woman feels she has a sense of control in labour and is well supported, she is more likely to experience her childbirth care as positive. [15][16][17] However, while there is a large body of literature on women's experiences of childbirth care from North America, northern Europe and Australasia, there is far less research on this topic from Eastern European countries, where maternal engagement in maternity care choices and practices appears to be less prominent. Few studies have analysed women's attitudes towards maternity care in Lithuania. One of them revealed that more than half of the women were satisfied with fulfilment of their expectations during childbirth and postpartum care expectations. 18 The aim of the study was to analyse women's experiences and views on childbirth care in Lithuania. Specific goals were to explore women's reports of positive aspects of care by birthplace and to identify areas in which women would like to see improvements in the future.

| Procedure and sample
The study used the Babies Born Better (B3) survey as the data collection instrument. The B3 survey is an ongoing longitudinal international project, examining the views and experiences of childbirth care. It aims to highlight areas of good practice in childbirth care around the world, geo mapped to place of birth, so that all services can learn and apply what works well in those services rated most highly by respondents. The survey was developed and refined as part of two EU-funded COST Actions (IS0907 and IS1405). These Actions were designed to advance scientific knowledge about ways of improving maternity care provision and outcomes for mothers, babies and families across Europe, by understanding what works, for whom and in what circumstances. The survey is based on a salutogenic perspective, which concentrates on health promotion and understanding what goes well, while including negative outcomes and experiences, in a health continuum. 19 The key concepts of salutogenesis are 'meaningfulness, comprehensibility and manageability'. These underpin a core construct of a 'Sense of Coherence' (SoC). Research taking a salutogenically oriented approach is especially important in maternity care systems, as most mothers and babies are healthy. 20,21 This study is, therefore, broadly based on the salutogenic philosophy, as opposed to being designed directly to measure the core concepts or the SoC.
The participants of the study were women who have given birth within 5 years of the date they complete the survey and who gave ŠIRVINSKIENĖ ET AL. | 1515 birth in Lithuania. The survey was run on an online platform (Survey Monkey ® ). It was hosted through an online portal (http://www. babiesbornbetter.org/surveyportal) and promoted online through social media (Facebook and Twitter), posts on COST Action member blogs and websites, discussion forums and maternity-related websites in each participating country. Papers of Austria, 22 Norway, 23 Spain, 24 Romania, 25 Croatia, 26

| Setting
In Lithuania, women can choose a governmental or private hospital for labour and birth. In both cases, care is provided by a physician-led team which consists of obstetricians and midwives. Only some wards in a few hospitals provide midwife-only-led delivery care. In governmental settings, the payment for care is covered by insurance; however, families could pay for some additional services out of pocket. According to official statistical data, the total number of births in 2015 in Lithuania was 28608.
Caesarean section was performed in 21.9% of all births (38.5%-elective, 61.5%-emergency caesarean). The rate of premature birth was 5.4%, and stillbirth-4.7%. 29 Childbirth care at home was illegal during the survey period, and homebirths were not included in the official statistics. However, there was an active debate in society about changing the regulation around the place of birth. At the time of reporting on this survey, there is a government order describing home birth procedures, but no legal organisation has applied for a licence to provide this service.
Despite being illegal, a small percentage of births do, in fact, take place at home. Thirteen women in our study reported homebirth.

| Instruments
The B3 survey comprises 16 core questions, a comments box and two questions relating to information about the study results, and willingness to be contacted about future research. In the first (quantitative) part of the survey, information is collected on demographic characteristics, pregnancy problems, place of birth and the cadre(s) of staff who provided childbirth care. In the second   Figure 1).

Content analysis and counts of responses to open-ended
questions revealed that the most saturated category with the highest percentage of responses relating to the best aspects of childbirth care in Lithuania was Individual experience of childbirth care (49.5%).
For the aspects that respondents would like to change, the most saturated category with the highest percentage of responses was Service at birthplace (37.9%).

| Service at birthplace
Nearly one in four answers were related to the category of Service at the place of birth as part of the best aspects of care and more than one in three as aspects that women would like to change in childbirth F I G U R E 1 Map of categories and subcategories representing women's childbirth care experiences and views in Lithuania. and they supplied pyjamas, bedding, and mats when we needed them'; 'There was fostering of breastfeeding (they did not suggest using formula)'. Though, some women were unhappy because they were advised to switch to formula, or they got poor support or advice about breastfeeding: 'Staff had an attitude that it is normal for a firsttime mother not to know how to breastfeed, and to develop sore nipples'. They emphasised the need for more developed education about breastfeeding: 'Give special attention to mother and baby in the first 24 hours, explaining to change a diaper and to feed the baby'.

| Emotional experience at the place of birth
The codes with the highest number of allocated responses were the newborn when the newborn is separated from the mother due to the illness'), as well as the need for them to be allowed to stay together for the first night. Women also talked about the encouragement of mothers' esteem, which included staff's consideration of women's needs, wishes and requests during and after labour: 'I could just be with my husband; the midwife was calmly entering only when it was needed'.

| Individually experienced care
Leaving the personal space for women and their close ones was one of the verbalised needs: 'There was minimal interference of personal space'; 'They did not interfere in the process, they just observed it'.
Otherwise, lack of esteem in some cases included lack of respect for women's wishes, negative comments in their presence, being ignored, and being exposed to too many personnel member: 'I wanted to rest a little bit between the contractions, but the physician instructed me to move'. In some cases women felt ignored and depersonalised: Another topic of women's answers was out-of-pocket payments.
Women indicated that they enjoyed personalised care at the hospital, but they paid it out of pocket. This practice was also poorly regulated and out-of-pocket direct payment was illegal. Despite the fact that professionalism did not differ between the payment and nonpayment cases, women preferred to do this to ensure their autonomy during the birth process: 'The doctor was amazing, but I had an agreement about birth care with him'; 'I had paid to the anaesthesiologist; she was very kind'. Out-of-pocket payments were mentioned as negative aspect of childbirth care. Women advocated for higher salaries for personnel or regret too expensive payments both for personnel or for advanced service in the hospital. Some of them felt forced to provide out-of-pocket payments, and some of them were afraid not to suggest these payments expecting a lower quality of service. Some of them sided with the movement not to support out-of-pocket payment practices: 'I don't think women should have to give "envelopes" [bribe, illegal payment]'.
Amongst positive aspects of childbirth care extra services were mentioned, which were a deviation from normal care, such as a possibility to be discharged earlier, some gifts, and so forth: 'Early discharged home'; 'The baby was watched another six days after birth, although Apgar score was 9 points'.
Some women positively commented that they did not experience some of the negative things which had been discussed in the media.
They were happy to have a more naturalistic birth and postpartum care approach, more personalised attention after delivery or even less hospital personnel in attendance than they expected, but more of their husbands' attention during labour, avoidance of moralisation and disrespectful behaviour and even the provision of small talk for creating comfort: 'It was night and the doctor was sleepingwe were calmer'; 'Very caring and non-moralising environment'.
Women also wanted more respect for the privacy and sacredness of birth, quiet discussion amongst personnel, possibility not to be Despite the fact that some women reported paternalistic attitude-based practice, others appreciated a shift towards patientoriented care. This suggests that the Lithuanian healthcare system is in transition towards improvement. This trend is reinforced in the findings of more recent surveys. 30 Our study revealed that a sense of empowerment in maternity care is an important expectation of women. This is beneficial to maternal wellbeing. Both empowerment and a sense of control have been reported as a central need during childbirth 31 and as one of the main aspects of a positive experience of childbirth. 15,32 Lack of a sense of empowerment was a notable dissatisfaction factor. 33 In support of this finding, a systematic review of 27 articles showed that interventions supporting empowerment are associated with reduced perinatal depressive symptoms and rates of prematurity/low birth weight. 34 Being in a comfortable environment was also highly valued.  36 In our study, the partner support was not verbalised possibly due to the understanding that spouse participation is a natural process and more painful topics such as empowerment or provision of care were highlighted.
Out-of-pocket payments and exclusive, additional services are part of healthcare in many other post-Soviet countries. 37 This is partly illustrated in the three aspects that did not fit the a priori theoretical frame; namely the debate on home birth legislation; the need for bribes to obtain some aspects of standard care; and miscommunication on issues that were important for the mother, which they felt as scaremongering, rather than as collaborative encouragement.
The home birth issue has been discussed above. The issue of bribes for improved services is more nuanced. In Soviet times, the political will was to keep salaries for physicians low, 'because the folk will feed them'. This created the tradition of out-of-pocket payment for health services or even feeling in the society of a need to pay out of pocket even if it was not asked for. Even though these activities are now illegal, there is a broad discussion in Lithuania about continued willingness to give and willing to receive these payments.
Society was in transition on that issue during the study and we discovered a tension and dilemma amongst young mothers-is a service better because of payment; or is it worse because of nonpayment; and do I feel I want to pay when the service was good because in this way I want to show appreciation?
As the main care aspects which were discussed in the Lithuanian sample were related to services delivered by healthcare personnel, such as psychological support, empowerment, communication and illegal payments are reconstructed as a tool to increase the probability of enhanced care. This can create social tension between the providers and women, even though personal attitudes towards the ethics of these payments differ across the population. 38

| Limitations
Online surveys can attract more proactive women than those in the general population. In addition, distribution using parental forums could have engaged more respondents who are inclined to be active change agents. This could also be seen as a strength, however, as women in such groups are often addressing issues that matter to many others who remain silent, and so their contributions can allow important issues to surface. Another limitation is that a limited number of sociodemographic characteristics were collected in the survey. It is possible that participants were more educated, and more motivated to report suggestions for changes in the maternity care system than the general population, as this is often the case for survey responders. 39

| CONCLUSIONS
The findings of this study suggest that the Lithuanian healthcare system is in transition from prior paternalistic attitude-based practices to a shift towards patient-oriented care. Implementation of improvements suggested by Lithuanian respondents to the B3 survey would require some additional services, improved emotional and intrapersonal aspects of care and a more active role for women.
Further research could entail the use of the geomapping capacity of the survey to locate hospitals where women only report good care, and to undertake a more in-depth study, including interviews with staff and women, to establish what they are doing well, in line with salutogenic principles.

AUTHOR CONTRIBUTIONS
Study design, supervision, review and editing: Giedrė Širvinskienė.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study (in Lithuanian) are available on request from the corresponding author. The data are not publicly available due to privacy.