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The birth bed: A qualitative study on the views of midwives regarding the use of the bed in the birth space
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ORIGINAL RESEARCH – QUALITATIVE
The birth bed: A qualitative study on the views of midwives regarding the use of the bed in the birth space B. Townsend a,*, J. Fenwick a, V. Thomson a, M. Foureur b a b
Menzies Health Institute of Queensland, Griffith University and Gold Coast University Hospital, Australia Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
A R T I C L E I N F O
Article history: Received 20 April 2015 Received in revised form 30 July 2015 Accepted 16 August 2015 Keywords: Birth environment Clinical practice Birth bed Design Midwives
A B S T R A C T
Background: There is a growing body of evidence to show that the birth environment can influence women’s experiences of labour and birth as well as midwifery practice. A common feature of the modern birth space is the bed. Knowledge about how the use of the bed shapes clinicians’ perceptions and attitudes is limited. Aim: The aim of this paper is to describe midwives’ perceptions of the birth bed. Method: Qualitative descriptive design. Fourteen midwives from one Queensland maternity unit participated in digitally recorded and transcribed interviews. Thematic analysis was used to analyse the data set. Findings: Four themes were identified. The first, described beliefs that using the bed formed part of women’s childbirth expectations. A second theme, captured midwives’ perceptions that the bed was also an object required to safely undertake their work. The third theme described how others commonly worked to ensure the woman stayed off the bed. Lastly, there was evidence that whilst wanting to avoid the use of the bed, some were reluctant, fearing potential reprimand. Conclusion: The themes highlight differences in how the midwives conceptualised the use of a bed within a birth space. While some avoided the use of the bed altogether others would only conceive of women moving off the bed if everything was ‘normal’. How the bed was culturally constructed appeared to dictate clinical practice. Reflecting on the meaning of an object, such as the bed, is important if clinicians are to fully understand how the birth environment influences their practice and thus women’s experiences of labour and birth. ß 2015 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
1. Introduction Giving birth is a unique life event that creates enduring memories for every woman. Although there are certain aspects of the physiological process of labour and birth we are yet to fully understand, we do know that one to one support during labour makes a significant difference to a woman achieving a normal birth.1 Likewise we now understand the benefits afforded to women who have access to a ‘known midwife’ across their entire childbirth journey.2–4 In resource rich countries, such as Australia, investigating models of care and their association with maternal and neonatal outcomes, especially rising rates of intervention or the lack thereof,
* Corresponding author. Tel.: +61 435448706. E-mail address: b.townsend@griffith.edu.au (B. Townsend).
has also led researchers to question the role the birth environment may play in how a woman feels and responds to her labour and subsequently perceives the experience.5–10 The interplay between the birth environment (or space) and a woman’s hormone response to her labour is something that many working with childbearing women have traditionally ‘sensed’ to be true. However it has only been fairly recently that the semiotics of the space (the meaning associated with space) have started to receive focused attention.11–13 Work by Australian researchers has yielded important insights into birth suite design and the features that are likely to support physiological birth.14–16 For example, natural materials, dim lighting and the use of sensory materials, create a more relaxing calming place. In turn the ability of women to remain relaxed and in the moment helps the production of their own natural pain relieving endorphins and oxytocin. Conversely this work identified features that possibly hinder normal birth. For example, poor way
http://dx.doi.org/10.1016/j.wombi.2015.08.009 1871-5192/ß 2015 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Please cite this article in press as: Townsend B, et al. The birth bed: A qualitative study on the views of midwives regarding the use of the bed in the birth space. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.08.009
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finding, lack of warmth in the colour scheme, use of stainless steel, no ability to control lighting and temperature, doors that were left open, exposed equipment, limited place and space for families and women’s belongings and no ability to access water immersion.16 In addition, the team identified that the ‘bed’ remained a dominant and central feature of most Australian birth rooms. Certainly, the results of a large maternity survey conducted in Queensland, Australia,17 support this assertion. In this study 88.3% of women who had a vaginal birth reported giving birth on a bed with 43.3% stating they did so flat on their backs. Davis and Walker18 have previously described the ‘standard’ hospital labour room as a place that conveys to women and their supporters that they are vulnerable and undertaking somewhat of a dangerous journey; ‘‘a woman at risk of peril and death rather than a woman in rapture to birth and life’’ (p. 386).18 Likewise, Fahy and Parratt described the common clinical ‘bed dominant birth space’ as lacking privacy and one that is associated with a sense of ‘surveillance’.11 In comparison these researchers found ‘home like’ birth spaces resonated comfort, calmness, security and safety thus becoming a woman’s ‘sanctum’. Indeed Hodnett et al.’s19 Cochrane review, which compared women using a standard hospital room vs a ambient clinical environment, found that 86% of women labouring in standard rooms spent at least 75% of their labour on the bed. Conversely, the majority of the women (65%) in the ambient room did not use the bed. The review also noted that there was an increase use of syntocinon for augmentation in women in the standard room compared to the ambient room. Theorising the influence of the birth environment on women’s physiological responses during labour has also led to questions about how this same environment may impact clinical practice. The New Zealand midwives in Davis and Walker’s study18 articulated how the ‘highly obstetric’ space made them fearful, changing the way they practised. In the Cochrane review19 comparing standard and ambient birth rooms’, midwives were noted to spend more time with women in the ambient birth space. Similarly Canadian midwives, when comparing working with women at home as opposed to hospital, also acknowledged how the different birth environments influenced their practice.20 While the 26 midwives in this qualitative study acknowledged the less than ideal nature of the medicalised hospital environment, they also spoke of working hard to create a comfortable space for women as well as a hybrid work space for themselves. Hammond et al.21 have similarly identified how Australian midwives are affected by the design of the hospital birth room. In this study midwives perceived that the way the room ‘looked and felt’ affected the quality of care they provided the labouring woman. Some of the midwives participating in this study admitted that a lack of space and comfort in the birth room commonly resulted in them spending less time in the room with the woman. The authors concluded that the current design of the standard ‘hospital birth room’ cluttered with equipment and with the ‘bed’ as a central feature was not conducive to current midwifery practice and the facilitation of normal birth. Health care providers, particularly midwives, are in the unique position of being able to make decisions around how a woman’s birth space is configured. Although the majority of Birth Suites continue to reflect in their design the dominance of a medical culture, there is room for clinician creativity. There remains limited understanding, however, of how clinicians think about birth space.
environment. This was part of a large programme of work exploring birth unit design 16,20. 3. Method A qualitative descriptive approach was used. Descriptive approaches are considered an appropriate choice if the phenomenon is inadequately defined or conceptualised and typically incorporate an eclectic combination of methods in data collection and analysis.22 Arguably the participants’ subjective descriptions provide insight into understanding the human experience.23–25 3.1. Setting The study took place at a regional Queensland public hospital. The Birth Suite had eight birthing rooms, each with shower facilities. Standard to each room was a bed that was surrounded by an abundance of visual medical equipment. There was minimal decoration. At one end of the Birth Suite were an additional two Birth Centre rooms. These rooms had been purpose built and each contained a large pool which was the central feature of the room. The beds were pushed to one side and covered with domestic-type quilts rather than hospital-type, white linen. The Birth Centre rooms were more aesthetically pleasing with wooden floors, artwork, dimmable lamps and all equipment hidden from sight. Only clients of the Midwifery Group Practice (caseload care) accessed these rooms. Interviews were conducted just prior to the hospital relocating to a new tertiary unit at the end of 2013. 3.2. Participants, recruitment and data collection. Following approval from both hospital and university ethics committee’s (HREC/12/QCG/51; NRS/52/12/HREC), planned as well as opportunistic, in-service information sessions were held for midwifery staff who worked in both the Birth Centre and Birth Suite to explain what the study was about. Participant information sheets and consent forms were distributed to interested staff. Once consent to participate was gained, a time and location, suitable to the clinician, was made to conduct a one-off, digitally audio recorded, unstructured interview. At the beginning of the interview each clinician completed a short demographic sheet that collected information such as age and years of experience. The digital recorder was then switched on and participants were asked two broad overarching questions; ‘‘Can you share your perceptions of the birth environment and how you encourage women to use the birth space’’. As the interview progressed participants were asked to clarify and expand their responses as the need arose. Contemporaneous field notes were taken by the interviewer. The interviews lasted between 30 and 60 min. Fourteen midwives agreed to participate in the interviews. One was a student midwife. To maintain confidentiality the student is considered as a midwife throughout this paper. All were female and aged between 25 and 61 years (mean 43). Some 17% had a Masters degree, 50% an undergraduate degree, 11% a diploma and 22% a midwifery certificate. Sixty-one percent of midwives had children of their own. Thirty-six percent of participants had worked in both the Birth Centre and standard Birth Suite whilst 57% had only worked in the standard Birth Suite and 7% only in the Birth Centre.
2. Aim
3.3. Data analysis
The aim of this paper is to describe midwives’ perceptions of the birth bed. The findings were derived from interviews where midwives where asked to share their perceptions of the birth
Interviews were transcribed verbatim and all identifying material removed. Thematic analysis and the techniques associated with constant comparison were used to analyse the data
Please cite this article in press as: Townsend B, et al. The birth bed: A qualitative study on the views of midwives regarding the use of the bed in the birth space. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.08.009
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set.26,27 Initially all transcripts were read and initial thoughts captured in wide margins and subsequently discussed by the research team. Line by line coding then commenced. This process consisted of underlining words and phrases and assigning meaning. While the first and third authors did the initial coding and grouping all the researchers subsequently assisted revising the clustered data. As data was constantly compared these groupings became saturated and themes were identified. Links between associated subthemes themes were then explored. The research team used audit trails (word tables with columns of data, concepts, and themes) to assist them revise the data and keep a record of the decisions made about concept grouping. These audit trails assisted in data management and could be easily shared between researchers. Regular team meetings, where emerging themes were shared and discussed, also assisted the decision making process around theme development. One major theme to emerge related to midwives’ perceptions of the birth bed. The presentation of the four themes that focused on the bed are presented in this paper. 4. Findings Four themes were identified that related specifically to the concept of the ‘birth bed’. All but one of the participants described the bed as the most dominant feature of the birth space. There were differences, however, in how participants conceptualised the use of the bed. Some 50% of midwives expressed the opinion that women preferred to give birth on the bed. Subsequently many went on to describe how the bed served a particular purpose in assisting them undertake the important activity of ‘assessment’. While some midwives avoided the use of the bed altogether, others would only consider women moving off the bed if everything was ‘normal’. Finally, there was a group of participants that understood the benefits of avoiding the bed whilst also expressing reluctance to change the space for fear of being reprimanded.
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they required medical support or assistance. For example, women being induced were perceived by some as likely to not want to ‘drag’ their intravenous pole around suggesting that the bed was the ‘default’ place for them to be. 4.2. ‘I need the bed – she needs the bed’ Subsequently a number of clinicians went on to highlight the role of the ‘bed’ in assisting them undertake a number of important activities. The bed was particularly singled out for tasks such as assessing the progress of labour, using continuous electronic fetal monitoring and for any situation where the woman might be deemed ‘at risk’ (e.g. breech birth). Thus women needed to be on the bed to receive an initial assessment. Midwives described the importance of using the bed to establish if the baby was ‘head down’, listen to the fetal heart and do a ‘proper assessment’ to ‘make sure she’s normal’. As one midwife stated, ‘then once you know everything’s fine you let them get on with it. So I think that is why generally they go to the bed first because it’s easy to get all that done.’ For many a woman’s ‘risk’ status was the deciding factor on how they used the birth environment and subsequently the bed; ‘If I have a high risk woman I’m less likely to get her on the floor with a birth mat because I know that I need to keep space if there’s an emergency’. Having women on the bed was perceived as safer ensuring the midwife’s ability to access the woman and move around the room. As one midwife explained; ‘because I guess if they are in the bed I can get to the right and left side of them if I need to get around and stuff like that if they’re in the bed. I’d rather be able to get to both sides of them.’ Some midwives also considered it more appropriate that women be on the bed when requiring a consultation with another member of the team such as an obstetrician. Conversely, they also perceived that doctors would prefer women in this position. 4.3. ‘I help her avoid the bed’
4.1. ‘Women want to use the bed’ Ten of the fourteen participants stated that they believed women expected, wanted or preferred using the bed during labour and/or birth. Participants hypothesised that women’s expectations around using the birth bed were most likely the result of social and multimedia messages that depicted, and thus constructed, the bed as a necessary part of the birth process. For example, one midwife stated: ‘A lot of women think that they have to birth on the bed and that’s just how it’s meant to be. So when you tell them oh you don’t have to lie on the bed, they are in a bit of shock, like oh I thought that’s kind of how it’s done.’ A number of midwives went on to describe how challenging it could be to get a woman off the bed or even to encourage them to use different positions. One midwife expressed the opinion that considerable expertise was required to motivate women to get off the bed; ‘I would say about 40 per cent of the time there’s a lot of resistance. You really have to work hard in order to get them off the bed but, I would say that it is another skill that you learn.’ The perception of one midwife, which also resonated with others, was that women commonly used the bed to claim ownership of the room and to non-verbally ask for help. ‘They’ll come in and the first thing they do with the space is go and lie on the bed [laughs] and that’s sort of their way of going I’m here, I’m feeling really overwhelmed, I’m going to lie on this bed and you’re going to help me if you get what I mean because I’m over it.’ Several midwives also made assumptions about how women may or may not feel about using the space in circumstances where
There were some notable differences between participants in how they spoke about the birth space and the use of the bed. Midwives who had experience of providing intrapartum care in a range of different maternity setting and birth environments such as the Birth Centre described how they routinely worked with the space to ensure women avoided or were distracted from using the bed. For example, participants shared how they raised the bed to make it a ‘leaning’ rather than a ‘sitting’ object. Other objects such as birth balls, mats and bean bags were often placed in front of the bed or in the space to attract the woman’s attention. Additionally, in the Birth Centre the beds were routinely pushed to the side and covered with coloured quilts. There were midwives working in the Birth Suite who also followed this lead; ‘I have actually moved the bed totally up towards the window, covered it over. So that it could be just be used more as a leaning tool as opposed to looking like a bed.’ Clinicians who were comfortable working in a space where the bed was not central shared how they routinely did observations and assessments in chairs, on the floor, or in the shower. If a bed was used to assess a woman they quickly moved women off once the assessment was completed. Telemetry for continuous fetal monitoring was well used by this group of midwives; ‘I plug them onto the continuous monitor without the cords and I’ll say they can use the shower and they can use the birth ball. So that they don’t have that restriction of the bed.’ Those midwives who had worked in a caseload model also talked about the importance of preparing women during pregnancy to be mobile and active during labour. The use of oils, music, lighting and bringing in familiar domestic objects from home also featured in these conversations. Clinicians working in Birth Suite echoed similar sentiments stating that those women
Please cite this article in press as: Townsend B, et al. The birth bed: A qualitative study on the views of midwives regarding the use of the bed in the birth space. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.08.009
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who had been to ‘classes’ or educated themselves were more likely to mobilise. 4.4. ‘I’m too fearful to avoid the bed’ There was some indication in the data set that a small number of midwives, regardless of their experience, while recognising and acknowledging the importance of creating a space where the bed was not dominant, expressed feeling ‘nervous’ and ‘anxious’ about altering the position of the bed. One midwife said ‘I don’t have the guts to do it’. For the most part this appeared to be driven by the perception it would be ‘frowned on’ by their ‘senior colleagues’ and a fear that if an emergency should occur they would ‘get into trouble’ for not having the bed in its ‘correct’ position. At times this even extended to offering women alternate positions on the bed. For example, one midwife verbalised how she would often consider encouraging a woman to use a different position on the bed but then change her mind as a result of perceived peer pressure; ‘You think oh maybe I should get them on all fours on the bed but because the next person that’s coming in to witness my birth isn’t going to be happy with it, you don’t.’ 5. Discussion The findings presented in this paper continue to support the notion that for most midwives the bed remains a dominant feature of the birth space.7,16 It is interesting to note that in the first instance midwives considered that labouring women were in fact the ones choosing how the bed was utilised. Certainly De Jonge28 found that some women did indeed prefer to give birth on the bed. This was often in response to cultural norms and feelings of embarrassment. Later work De Jonge et al.29 identified social status as a factor with more educated women more likely to give birth in upright positions and away from the bed. The impact of social media was commonly blamed for influencing women’s childbirth expectations and thus how the bed might be used. There is little doubt that images and messages portrayed on social media sites such as Facebook,30 Twitter31 and YouTube32, as well as reality shows like ‘One Born Every Minute’33, and Google34 are major sources of information for women.35,36 The continued depiction of childbirth as a medical event through media such as these is pervasive. As others have attested the continual construction that birth needs to take place in a space designed only to deal with ‘acute care emergencies’ perpetuates a cultural norm around the birth bed as central, important and necessary to labour and birth (see, for example, Davis and Walker18). However, what became evident in this study was that some midwives were unable to appreciate how the environment, particularly the ‘bed’, might be influencing their own practice and construction of birth. These findings are in-line with the burgeoning evidence that demonstrates the mutually constitutive nature of design, environment and subjectivity (identity). Simply this means that design reflects the social and cultural understandings of those creating a particular space and those understandings are reproduced through design.37,38 Researchers have found that the way health care practitioners and patients react, feel and engage with the environment is dependent on the objects and physical design of the room.39–41 In regard to childbirth, Davis and Walker18 have argued strongly that the birthing environment plays a significant role in shaping the meaning of childbirth, the behaviours of childbearing women and also the practice of midwives. Likewise, and similar to our findings, Hammond et al.21 drew attention to how the prominence of the obstetric bed and the clinical nature of the birthing room reflected a biomedical discourse in which childbearing was constructed as a medical event and the woman as a ‘passive patient’. Childbearing women indeed ‘took to bed’ in hospital
environments, becoming passive, and midwives reported that they focused more on risk and monitoring in the tertiary setting because they were reminded of the ‘risky’ nature of childbirth by the design and technological features of tertiary birth units. Researchers such as Davis42 have concluded that it is not just the environment that dictates the practice but the types of activities that occur in that space. Davis suggests that it is the relationship (or lack of) between the woman and her midwife and the use of language in the birth space that ultimately distinguishes them as safe or unsafe. Seibold et al.43 looked at practices and perceptions of birth space in a unit before and after moving into a new unit. Conversely they found that practice was influenced mainly by the philosophy of the unit which was heavily based on reducing risk. Certainly there was evidence of this in our study. While acknowledging the benefits of reconfiguring a birth space to support normal birth practices and better meet the needs of the individual labouring woman, some midwives were unable to enact these practices for fear of attracting condemnation and recrimination, especially in a situation where an emergency might arise. This finding speaks to what Hunter44 has previously described as the ‘unwritten rules’ of the Birth Suite. In this work Hunter identified that senior midwives, working in hospital settings, commonly enforced a set of rules or expectations around how women should be managed during labour. Less experienced and/or midwives new to the environment struggled to challenge these, even when they knew the evidence did not support them, for fear of being labelled ‘non-compliant’ or a trouble maker and thus ‘not welcome’ as a team member. Understanding environments as having a discursive function (creating and reflecting) thus also helps to explain why midwives who had worked in the Birth Centre or other birth environments such as ‘women’s homes’ were decidedly different. For these midwives the bed was something to be avoided. If it was used, the bed’s purpose was very different: it commonly became a tool to increase a woman’s ability to mobilise and work with her body during contractions rather than an object to ‘lie on’. These midwives’ descriptions of practice reflected a construction of childbirth as a normal life event. Risk was seemingly absent from any decision making by these midwives about the bed. There is also growing evidence to suggest that space and place affect how midwives connect with women as well as affecting how comfortable they feel with their practice.18,20,45 Hammond et al.45 hypothesised that there may be a connection between the birth environment and the release of the neuropeptide oxytocin in midwives which in turn plays a role in helping them provide ‘emotionally sensitive’ care to the women in their care. Although still a theoretical argument in midwifery, other disciplines, such as sociology and nursing, have supported this idea.38,46 5.1. Limitations The findings presented in this paper were derived from a small convenience sample of midwives working in one maternity unit in southeast Queensland. The views expressed by the clinicians’ may have been influenced by interview bias and may not represent their clinical practice. As a result the findings are not generalised and need to be interpreted with caution. Despite these limitations the insights gained do add to the growing body of evidence on the effect of birth unit design on the birth experience of the woman as well as midwifery practice. 6. Conclusion The findings presented in this paper add to the growing body of work that explores the interplay between the birth environment, of which design is one aspect, and how people act and interact within a space. Objects within a space co-create meaning; that meaning is
Please cite this article in press as: Townsend B, et al. The birth bed: A qualitative study on the views of midwives regarding the use of the bed in the birth space. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.08.009
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shared and reproduced and reflected in the behaviours of those who inhabit the space. Most in this study acknowledged the persuasive nature of the bed especially for women. There was less awareness, however, of how the mere positioning of the bed reflected philosophy and subsequently dictated clinical practice. For some the centrality of the bed reinforced messages around the biomedical nature of birth and managing risk. For others the bed represented an object that needed to be repositioned, almost hidden, to facilitate normal birth. Midwives have the ability to reconfigure the birth space. Removing the bed from its standard central location is one simple but powerful action that has the potential to make a difference to how a woman might work with her body as she meets the challenge of labour. Likewise the messages and meaning created by this move will also help clinicians reconstruct childbirth and thus how they practice in the space. Keeping birth normal has significant implications for women, the connection they share with their newborns, family functioning and ultimately the wellness of our community. References 1. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2013;7(7):CD003766. 2. McLachlan HL, Forster DA, Davey MA, Farrell T, Gold L, Biro MA, et al. Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial. BJOG 2012;119(12):1483–92. 3. Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev 2013;8(8):CD004667. 4. Tracy SK, Hartz DL, Tracy MB, Allen J, Forti A, Hall B, et al. Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial. Lancet 2013;382(9906):1723–32. 5. Walton C. The birthplace in England study: methods, findings and evaluation. Br J Midwifery 2012;20(1):22–7. 6. Buckley S. Undisturbed birth. Nature’s blueprint for ease and ecstasy. United States: Midwifery Today, Inc.; 2002: 19. 7. Fahy K. Power and the social construction of birth territory. In: Fahy KM, Foureur M, Hastie C, editors. Birth territory and midwifery guardianship: theory for practice, education, and research. Books for midwives. New York/Edinburgh: Butterworth, Heinemann, Elsevier; 2008. 8. Nolan M, Smith J. Women’s experiences of following advice to stay at home in early labour. Br J Midwifery 2010;18(5):286–91. 9. Walsh D. Subverting the assembly-line: childbirth in a free-standing birth centre. Soc Sci Med 2006;62(6):1330. 10. Walsh DJ. ‘Nesting’ and ‘Matrescence’ as distinctive features of a free-standing birth centre in the UK. Midwifery 2006;22(3):228–39. 11. Fahy KM, Parratt JA. Birth territory: a theory for midwifery practice. Women Birth: J Aust Coll Midwives 2006;19(2):45–50. 12. Stenglin M, Foureur M. Designing out the Fear Cascade to increase the likelihood of normal birth. Midwifery 2013;29(8):819–25. 13. Walsh TC. Exploring the effect of hospital admission on contraction patterns and labour outcomes using women’s perceptions of events. Midwifery 2009;25(3):242–52. 14. Foureur M. Creating birth space to enable undisturbed birth. Birth territory and midwifery guardianship: theory for practice, education, and research. Books for midwives. New York/Edinburgh: Butterworth, Heinemann, Elsevier; 2008. 15. Foureur M, Hunter M. Place of birth. Midwifery: preparation for practice. Elseiver Health Science APAC; 2011: 104–24.
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16. Foureur MJ, Leap N, Davis DL, Forbes IF, Homer CES. Testing the Birth Unit Design Spatial Evaluation Tool (BUDSET) in Australia: a pilot study. HERD 2011;4(2):36–60. 17. McKinnon LC, Prosser SJ, Miller YD. What women want: qualitative analysis of consumer evaluations of maternity care in Queensland, Australia. BMC Pregnancy Childbirth 2014;14(1):366. 18. Davis D, Walker K. The corporeal, the social and space/place: exploring intersections from a midwifery perspective in New Zealand. Gender Place Cult 2010;17(3):377–91. 19. Hodnett ED, Stremler R, Weston JA, McKeever P. Re-conceptualizing the hospital labor room: the PLACE (Pregnant and Laboring in an Ambient Clinical Environment) pilot trial. Birth 2009;36(2):159–66. 20. Bourgeault IL, Sutherns R, Macdonald M, Luce J. Problematising public and private work spaces: midwives’ work in hospitals and in homes. Midwifery 2012;28(5):582–90. 21. Hammond A, Foureur M, Homer CSE. The hardware and software implications of hospital birth room design: a midwifery perspective. Midwifery 2014;30(7):825–30. 22. Sandelowski M, Barroso J. Handbook for synthesizing qualitative research. US: Springer Publishing Company; 2007. 23. Liamputtong P. Research methods in health: foundations for evidence-based practice. South Melbourne, Vic: Oxford University Press; 2013. 24. Polit-O’Hara D, Beck CT. Essentials of nursing research: appraising evidence for nursing practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010. 25. Schneider Z, Whitehead D, LoBiondo-Wood G, Haber J. Nursing and midwifery research: methods and appraisal for evidence-based practice. Chatswood, NSW: Elsevier Australia; 2013. 26. Guest G, MaQueen KM, Namey EE. Applied thematic analysis. Portland: Ringgold Inc.; 2012. 27. Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: implications for conducting a qualitative descriptive study. Nurs Health Sci 2013;15(3):398–405. 28. Jonge AD, Lagro-Janssen ALM. Birthing positions. A qualitative study into the views of women about various birthing positions. J Psychosom Obstet Gynaecol 2004;25(1):47–55. 29. de Jonge A, Rijnders MEB, van Diem MT, Scheepers PLH, Lagro-Janssen ALM. Are there inequalities in choice of birthing position? Midwifery 2009;25(4):439–48. 30. Inc f. https://www.facebook.com/. 2014. 31. Twitter. http://www.twitter.com/. 2014. 32. Inc G.P. http://www.youtube.com/. 2014. 33. Foster D, Brindley D, Hartley S, Sbs TV. One born every minute: series 3. 2012. 34. Inc G. https://www.google.com/. 2014. 35. VandeVusse L, Reality VVA. Television as a source of information about birth: the messages and their implications. J Midwifery Womens Health 2008;53(5):482. 36. West JE. Technology knows best: the cultural work of hospital birth in 21st century film. LitMed 2011;29(1):104. 37. Agnew J. Space place.The SAGE handbook of geographical knowledge – edited by John A. Agnew and David N Livingstone. Geogr Res 2012;(4):1. 38. Gieryn TF. A space for place in sociology. Annu Rev Sociol 2000;26(1):463–96. 39. Jewitt M. The rise and rise of the obstetric bed. Midwifery Matters 2012;132:11–6. 40. Keller R. The Sociology of Knowledge Approach to Discourse (SKAD). Hum Stud 2011;34(1):43–65. 41. Kress G, Van Leeuwen T. Reading images: the grammar of visual design. New York/London: Routledge; 2006. [ebooks C.]. 42. Davis D. The politics of practice: caseloading midwifery practice in New Zealand University of Technology Sydney, NSW. 2006. 43. Seibold C, Licqurish S, Rolls C, Hopkins F. ‘Lending the space’: midwives’ perceptions of birth space and clinical risk management. Midwifery 2010;26(5):526–31. 44. Hunter B. Emotion work and boundary maintenance in hospital-based midwifery. Midwifery 2005;21(3):253–66. 45. Hammond A, Foureur M, Homer CSE, Davis D. Space, place and the midwife: exploring the relationship between the birth environment, neurobiology and midwifery practice. Women Birth: J Aust Coll Midwives 2013;26(4):277. 46. Jonas-Simpson C. The possibility of changing meaning in light of space and place. Nurs Sci Q 2006;19(2):89–94.
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Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
ORIGINAL RESEARCH – QUALITATIVE
The birth bed: A qualitative study on the views of midwives regarding the use of the bed in the birth space B. Townsend a,*, J. Fenwick a, V. Thomson a, M. Foureur b a b
Menzies Health Institute of Queensland, Griffith University and Gold Coast University Hospital, Australia Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
A R T I C L E I N F O
Article history: Received 20 April 2015 Received in revised form 30 July 2015 Accepted 16 August 2015 Keywords: Birth environment Clinical practice Birth bed Design Midwives
A B S T R A C T
Background: There is a growing body of evidence to show that the birth environment can influence women’s experiences of labour and birth as well as midwifery practice. A common feature of the modern birth space is the bed. Knowledge about how the use of the bed shapes clinicians’ perceptions and attitudes is limited. Aim: The aim of this paper is to describe midwives’ perceptions of the birth bed. Method: Qualitative descriptive design. Fourteen midwives from one Queensland maternity unit participated in digitally recorded and transcribed interviews. Thematic analysis was used to analyse the data set. Findings: Four themes were identified. The first, described beliefs that using the bed formed part of women’s childbirth expectations. A second theme, captured midwives’ perceptions that the bed was also an object required to safely undertake their work. The third theme described how others commonly worked to ensure the woman stayed off the bed. Lastly, there was evidence that whilst wanting to avoid the use of the bed, some were reluctant, fearing potential reprimand. Conclusion: The themes highlight differences in how the midwives conceptualised the use of a bed within a birth space. While some avoided the use of the bed altogether others would only conceive of women moving off the bed if everything was ‘normal’. How the bed was culturally constructed appeared to dictate clinical practice. Reflecting on the meaning of an object, such as the bed, is important if clinicians are to fully understand how the birth environment influences their practice and thus women’s experiences of labour and birth. ß 2015 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
1. Introduction Giving birth is a unique life event that creates enduring memories for every woman. Although there are certain aspects of the physiological process of labour and birth we are yet to fully understand, we do know that one to one support during labour makes a significant difference to a woman achieving a normal birth.1 Likewise we now understand the benefits afforded to women who have access to a ‘known midwife’ across their entire childbirth journey.2–4 In resource rich countries, such as Australia, investigating models of care and their association with maternal and neonatal outcomes, especially rising rates of intervention or the lack thereof,
* Corresponding author. Tel.: +61 435448706. E-mail address: b.townsend@griffith.edu.au (B. Townsend).
has also led researchers to question the role the birth environment may play in how a woman feels and responds to her labour and subsequently perceives the experience.5–10 The interplay between the birth environment (or space) and a woman’s hormone response to her labour is something that many working with childbearing women have traditionally ‘sensed’ to be true. However it has only been fairly recently that the semiotics of the space (the meaning associated with space) have started to receive focused attention.11–13 Work by Australian researchers has yielded important insights into birth suite design and the features that are likely to support physiological birth.14–16 For example, natural materials, dim lighting and the use of sensory materials, create a more relaxing calming place. In turn the ability of women to remain relaxed and in the moment helps the production of their own natural pain relieving endorphins and oxytocin. Conversely this work identified features that possibly hinder normal birth. For example, poor way
http://dx.doi.org/10.1016/j.wombi.2015.08.009 1871-5192/ß 2015 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Please cite this article in press as: Townsend B, et al. The birth bed: A qualitative study on the views of midwives regarding the use of the bed in the birth space. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.08.009
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finding, lack of warmth in the colour scheme, use of stainless steel, no ability to control lighting and temperature, doors that were left open, exposed equipment, limited place and space for families and women’s belongings and no ability to access water immersion.16 In addition, the team identified that the ‘bed’ remained a dominant and central feature of most Australian birth rooms. Certainly, the results of a large maternity survey conducted in Queensland, Australia,17 support this assertion. In this study 88.3% of women who had a vaginal birth reported giving birth on a bed with 43.3% stating they did so flat on their backs. Davis and Walker18 have previously described the ‘standard’ hospital labour room as a place that conveys to women and their supporters that they are vulnerable and undertaking somewhat of a dangerous journey; ‘‘a woman at risk of peril and death rather than a woman in rapture to birth and life’’ (p. 386).18 Likewise, Fahy and Parratt described the common clinical ‘bed dominant birth space’ as lacking privacy and one that is associated with a sense of ‘surveillance’.11 In comparison these researchers found ‘home like’ birth spaces resonated comfort, calmness, security and safety thus becoming a woman’s ‘sanctum’. Indeed Hodnett et al.’s19 Cochrane review, which compared women using a standard hospital room vs a ambient clinical environment, found that 86% of women labouring in standard rooms spent at least 75% of their labour on the bed. Conversely, the majority of the women (65%) in the ambient room did not use the bed. The review also noted that there was an increase use of syntocinon for augmentation in women in the standard room compared to the ambient room. Theorising the influence of the birth environment on women’s physiological responses during labour has also led to questions about how this same environment may impact clinical practice. The New Zealand midwives in Davis and Walker’s study18 articulated how the ‘highly obstetric’ space made them fearful, changing the way they practised. In the Cochrane review19 comparing standard and ambient birth rooms’, midwives were noted to spend more time with women in the ambient birth space. Similarly Canadian midwives, when comparing working with women at home as opposed to hospital, also acknowledged how the different birth environments influenced their practice.20 While the 26 midwives in this qualitative study acknowledged the less than ideal nature of the medicalised hospital environment, they also spoke of working hard to create a comfortable space for women as well as a hybrid work space for themselves. Hammond et al.21 have similarly identified how Australian midwives are affected by the design of the hospital birth room. In this study midwives perceived that the way the room ‘looked and felt’ affected the quality of care they provided the labouring woman. Some of the midwives participating in this study admitted that a lack of space and comfort in the birth room commonly resulted in them spending less time in the room with the woman. The authors concluded that the current design of the standard ‘hospital birth room’ cluttered with equipment and with the ‘bed’ as a central feature was not conducive to current midwifery practice and the facilitation of normal birth. Health care providers, particularly midwives, are in the unique position of being able to make decisions around how a woman’s birth space is configured. Although the majority of Birth Suites continue to reflect in their design the dominance of a medical culture, there is room for clinician creativity. There remains limited understanding, however, of how clinicians think about birth space.
environment. This was part of a large programme of work exploring birth unit design 16,20. 3. Method A qualitative descriptive approach was used. Descriptive approaches are considered an appropriate choice if the phenomenon is inadequately defined or conceptualised and typically incorporate an eclectic combination of methods in data collection and analysis.22 Arguably the participants’ subjective descriptions provide insight into understanding the human experience.23–25 3.1. Setting The study took place at a regional Queensland public hospital. The Birth Suite had eight birthing rooms, each with shower facilities. Standard to each room was a bed that was surrounded by an abundance of visual medical equipment. There was minimal decoration. At one end of the Birth Suite were an additional two Birth Centre rooms. These rooms had been purpose built and each contained a large pool which was the central feature of the room. The beds were pushed to one side and covered with domestic-type quilts rather than hospital-type, white linen. The Birth Centre rooms were more aesthetically pleasing with wooden floors, artwork, dimmable lamps and all equipment hidden from sight. Only clients of the Midwifery Group Practice (caseload care) accessed these rooms. Interviews were conducted just prior to the hospital relocating to a new tertiary unit at the end of 2013. 3.2. Participants, recruitment and data collection. Following approval from both hospital and university ethics committee’s (HREC/12/QCG/51; NRS/52/12/HREC), planned as well as opportunistic, in-service information sessions were held for midwifery staff who worked in both the Birth Centre and Birth Suite to explain what the study was about. Participant information sheets and consent forms were distributed to interested staff. Once consent to participate was gained, a time and location, suitable to the clinician, was made to conduct a one-off, digitally audio recorded, unstructured interview. At the beginning of the interview each clinician completed a short demographic sheet that collected information such as age and years of experience. The digital recorder was then switched on and participants were asked two broad overarching questions; ‘‘Can you share your perceptions of the birth environment and how you encourage women to use the birth space’’. As the interview progressed participants were asked to clarify and expand their responses as the need arose. Contemporaneous field notes were taken by the interviewer. The interviews lasted between 30 and 60 min. Fourteen midwives agreed to participate in the interviews. One was a student midwife. To maintain confidentiality the student is considered as a midwife throughout this paper. All were female and aged between 25 and 61 years (mean 43). Some 17% had a Masters degree, 50% an undergraduate degree, 11% a diploma and 22% a midwifery certificate. Sixty-one percent of midwives had children of their own. Thirty-six percent of participants had worked in both the Birth Centre and standard Birth Suite whilst 57% had only worked in the standard Birth Suite and 7% only in the Birth Centre.
2. Aim
3.3. Data analysis
The aim of this paper is to describe midwives’ perceptions of the birth bed. The findings were derived from interviews where midwives where asked to share their perceptions of the birth
Interviews were transcribed verbatim and all identifying material removed. Thematic analysis and the techniques associated with constant comparison were used to analyse the data
Please cite this article in press as: Townsend B, et al. The birth bed: A qualitative study on the views of midwives regarding the use of the bed in the birth space. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.08.009
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set.26,27 Initially all transcripts were read and initial thoughts captured in wide margins and subsequently discussed by the research team. Line by line coding then commenced. This process consisted of underlining words and phrases and assigning meaning. While the first and third authors did the initial coding and grouping all the researchers subsequently assisted revising the clustered data. As data was constantly compared these groupings became saturated and themes were identified. Links between associated subthemes themes were then explored. The research team used audit trails (word tables with columns of data, concepts, and themes) to assist them revise the data and keep a record of the decisions made about concept grouping. These audit trails assisted in data management and could be easily shared between researchers. Regular team meetings, where emerging themes were shared and discussed, also assisted the decision making process around theme development. One major theme to emerge related to midwives’ perceptions of the birth bed. The presentation of the four themes that focused on the bed are presented in this paper. 4. Findings Four themes were identified that related specifically to the concept of the ‘birth bed’. All but one of the participants described the bed as the most dominant feature of the birth space. There were differences, however, in how participants conceptualised the use of the bed. Some 50% of midwives expressed the opinion that women preferred to give birth on the bed. Subsequently many went on to describe how the bed served a particular purpose in assisting them undertake the important activity of ‘assessment’. While some midwives avoided the use of the bed altogether, others would only consider women moving off the bed if everything was ‘normal’. Finally, there was a group of participants that understood the benefits of avoiding the bed whilst also expressing reluctance to change the space for fear of being reprimanded.
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they required medical support or assistance. For example, women being induced were perceived by some as likely to not want to ‘drag’ their intravenous pole around suggesting that the bed was the ‘default’ place for them to be. 4.2. ‘I need the bed – she needs the bed’ Subsequently a number of clinicians went on to highlight the role of the ‘bed’ in assisting them undertake a number of important activities. The bed was particularly singled out for tasks such as assessing the progress of labour, using continuous electronic fetal monitoring and for any situation where the woman might be deemed ‘at risk’ (e.g. breech birth). Thus women needed to be on the bed to receive an initial assessment. Midwives described the importance of using the bed to establish if the baby was ‘head down’, listen to the fetal heart and do a ‘proper assessment’ to ‘make sure she’s normal’. As one midwife stated, ‘then once you know everything’s fine you let them get on with it. So I think that is why generally they go to the bed first because it’s easy to get all that done.’ For many a woman’s ‘risk’ status was the deciding factor on how they used the birth environment and subsequently the bed; ‘If I have a high risk woman I’m less likely to get her on the floor with a birth mat because I know that I need to keep space if there’s an emergency’. Having women on the bed was perceived as safer ensuring the midwife’s ability to access the woman and move around the room. As one midwife explained; ‘because I guess if they are in the bed I can get to the right and left side of them if I need to get around and stuff like that if they’re in the bed. I’d rather be able to get to both sides of them.’ Some midwives also considered it more appropriate that women be on the bed when requiring a consultation with another member of the team such as an obstetrician. Conversely, they also perceived that doctors would prefer women in this position. 4.3. ‘I help her avoid the bed’
4.1. ‘Women want to use the bed’ Ten of the fourteen participants stated that they believed women expected, wanted or preferred using the bed during labour and/or birth. Participants hypothesised that women’s expectations around using the birth bed were most likely the result of social and multimedia messages that depicted, and thus constructed, the bed as a necessary part of the birth process. For example, one midwife stated: ‘A lot of women think that they have to birth on the bed and that’s just how it’s meant to be. So when you tell them oh you don’t have to lie on the bed, they are in a bit of shock, like oh I thought that’s kind of how it’s done.’ A number of midwives went on to describe how challenging it could be to get a woman off the bed or even to encourage them to use different positions. One midwife expressed the opinion that considerable expertise was required to motivate women to get off the bed; ‘I would say about 40 per cent of the time there’s a lot of resistance. You really have to work hard in order to get them off the bed but, I would say that it is another skill that you learn.’ The perception of one midwife, which also resonated with others, was that women commonly used the bed to claim ownership of the room and to non-verbally ask for help. ‘They’ll come in and the first thing they do with the space is go and lie on the bed [laughs] and that’s sort of their way of going I’m here, I’m feeling really overwhelmed, I’m going to lie on this bed and you’re going to help me if you get what I mean because I’m over it.’ Several midwives also made assumptions about how women may or may not feel about using the space in circumstances where
There were some notable differences between participants in how they spoke about the birth space and the use of the bed. Midwives who had experience of providing intrapartum care in a range of different maternity setting and birth environments such as the Birth Centre described how they routinely worked with the space to ensure women avoided or were distracted from using the bed. For example, participants shared how they raised the bed to make it a ‘leaning’ rather than a ‘sitting’ object. Other objects such as birth balls, mats and bean bags were often placed in front of the bed or in the space to attract the woman’s attention. Additionally, in the Birth Centre the beds were routinely pushed to the side and covered with coloured quilts. There were midwives working in the Birth Suite who also followed this lead; ‘I have actually moved the bed totally up towards the window, covered it over. So that it could be just be used more as a leaning tool as opposed to looking like a bed.’ Clinicians who were comfortable working in a space where the bed was not central shared how they routinely did observations and assessments in chairs, on the floor, or in the shower. If a bed was used to assess a woman they quickly moved women off once the assessment was completed. Telemetry for continuous fetal monitoring was well used by this group of midwives; ‘I plug them onto the continuous monitor without the cords and I’ll say they can use the shower and they can use the birth ball. So that they don’t have that restriction of the bed.’ Those midwives who had worked in a caseload model also talked about the importance of preparing women during pregnancy to be mobile and active during labour. The use of oils, music, lighting and bringing in familiar domestic objects from home also featured in these conversations. Clinicians working in Birth Suite echoed similar sentiments stating that those women
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who had been to ‘classes’ or educated themselves were more likely to mobilise. 4.4. ‘I’m too fearful to avoid the bed’ There was some indication in the data set that a small number of midwives, regardless of their experience, while recognising and acknowledging the importance of creating a space where the bed was not dominant, expressed feeling ‘nervous’ and ‘anxious’ about altering the position of the bed. One midwife said ‘I don’t have the guts to do it’. For the most part this appeared to be driven by the perception it would be ‘frowned on’ by their ‘senior colleagues’ and a fear that if an emergency should occur they would ‘get into trouble’ for not having the bed in its ‘correct’ position. At times this even extended to offering women alternate positions on the bed. For example, one midwife verbalised how she would often consider encouraging a woman to use a different position on the bed but then change her mind as a result of perceived peer pressure; ‘You think oh maybe I should get them on all fours on the bed but because the next person that’s coming in to witness my birth isn’t going to be happy with it, you don’t.’ 5. Discussion The findings presented in this paper continue to support the notion that for most midwives the bed remains a dominant feature of the birth space.7,16 It is interesting to note that in the first instance midwives considered that labouring women were in fact the ones choosing how the bed was utilised. Certainly De Jonge28 found that some women did indeed prefer to give birth on the bed. This was often in response to cultural norms and feelings of embarrassment. Later work De Jonge et al.29 identified social status as a factor with more educated women more likely to give birth in upright positions and away from the bed. The impact of social media was commonly blamed for influencing women’s childbirth expectations and thus how the bed might be used. There is little doubt that images and messages portrayed on social media sites such as Facebook,30 Twitter31 and YouTube32, as well as reality shows like ‘One Born Every Minute’33, and Google34 are major sources of information for women.35,36 The continued depiction of childbirth as a medical event through media such as these is pervasive. As others have attested the continual construction that birth needs to take place in a space designed only to deal with ‘acute care emergencies’ perpetuates a cultural norm around the birth bed as central, important and necessary to labour and birth (see, for example, Davis and Walker18). However, what became evident in this study was that some midwives were unable to appreciate how the environment, particularly the ‘bed’, might be influencing their own practice and construction of birth. These findings are in-line with the burgeoning evidence that demonstrates the mutually constitutive nature of design, environment and subjectivity (identity). Simply this means that design reflects the social and cultural understandings of those creating a particular space and those understandings are reproduced through design.37,38 Researchers have found that the way health care practitioners and patients react, feel and engage with the environment is dependent on the objects and physical design of the room.39–41 In regard to childbirth, Davis and Walker18 have argued strongly that the birthing environment plays a significant role in shaping the meaning of childbirth, the behaviours of childbearing women and also the practice of midwives. Likewise, and similar to our findings, Hammond et al.21 drew attention to how the prominence of the obstetric bed and the clinical nature of the birthing room reflected a biomedical discourse in which childbearing was constructed as a medical event and the woman as a ‘passive patient’. Childbearing women indeed ‘took to bed’ in hospital
environments, becoming passive, and midwives reported that they focused more on risk and monitoring in the tertiary setting because they were reminded of the ‘risky’ nature of childbirth by the design and technological features of tertiary birth units. Researchers such as Davis42 have concluded that it is not just the environment that dictates the practice but the types of activities that occur in that space. Davis suggests that it is the relationship (or lack of) between the woman and her midwife and the use of language in the birth space that ultimately distinguishes them as safe or unsafe. Seibold et al.43 looked at practices and perceptions of birth space in a unit before and after moving into a new unit. Conversely they found that practice was influenced mainly by the philosophy of the unit which was heavily based on reducing risk. Certainly there was evidence of this in our study. While acknowledging the benefits of reconfiguring a birth space to support normal birth practices and better meet the needs of the individual labouring woman, some midwives were unable to enact these practices for fear of attracting condemnation and recrimination, especially in a situation where an emergency might arise. This finding speaks to what Hunter44 has previously described as the ‘unwritten rules’ of the Birth Suite. In this work Hunter identified that senior midwives, working in hospital settings, commonly enforced a set of rules or expectations around how women should be managed during labour. Less experienced and/or midwives new to the environment struggled to challenge these, even when they knew the evidence did not support them, for fear of being labelled ‘non-compliant’ or a trouble maker and thus ‘not welcome’ as a team member. Understanding environments as having a discursive function (creating and reflecting) thus also helps to explain why midwives who had worked in the Birth Centre or other birth environments such as ‘women’s homes’ were decidedly different. For these midwives the bed was something to be avoided. If it was used, the bed’s purpose was very different: it commonly became a tool to increase a woman’s ability to mobilise and work with her body during contractions rather than an object to ‘lie on’. These midwives’ descriptions of practice reflected a construction of childbirth as a normal life event. Risk was seemingly absent from any decision making by these midwives about the bed. There is also growing evidence to suggest that space and place affect how midwives connect with women as well as affecting how comfortable they feel with their practice.18,20,45 Hammond et al.45 hypothesised that there may be a connection between the birth environment and the release of the neuropeptide oxytocin in midwives which in turn plays a role in helping them provide ‘emotionally sensitive’ care to the women in their care. Although still a theoretical argument in midwifery, other disciplines, such as sociology and nursing, have supported this idea.38,46 5.1. Limitations The findings presented in this paper were derived from a small convenience sample of midwives working in one maternity unit in southeast Queensland. The views expressed by the clinicians’ may have been influenced by interview bias and may not represent their clinical practice. As a result the findings are not generalised and need to be interpreted with caution. Despite these limitations the insights gained do add to the growing body of evidence on the effect of birth unit design on the birth experience of the woman as well as midwifery practice. 6. Conclusion The findings presented in this paper add to the growing body of work that explores the interplay between the birth environment, of which design is one aspect, and how people act and interact within a space. Objects within a space co-create meaning; that meaning is
Please cite this article in press as: Townsend B, et al. The birth bed: A qualitative study on the views of midwives regarding the use of the bed in the birth space. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.08.009
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shared and reproduced and reflected in the behaviours of those who inhabit the space. Most in this study acknowledged the persuasive nature of the bed especially for women. There was less awareness, however, of how the mere positioning of the bed reflected philosophy and subsequently dictated clinical practice. For some the centrality of the bed reinforced messages around the biomedical nature of birth and managing risk. For others the bed represented an object that needed to be repositioned, almost hidden, to facilitate normal birth. Midwives have the ability to reconfigure the birth space. Removing the bed from its standard central location is one simple but powerful action that has the potential to make a difference to how a woman might work with her body as she meets the challenge of labour. Likewise the messages and meaning created by this move will also help clinicians reconstruct childbirth and thus how they practice in the space. Keeping birth normal has significant implications for women, the connection they share with their newborns, family functioning and ultimately the wellness of our community. References 1. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2013;7(7):CD003766. 2. McLachlan HL, Forster DA, Davey MA, Farrell T, Gold L, Biro MA, et al. Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial. BJOG 2012;119(12):1483–92. 3. Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev 2013;8(8):CD004667. 4. Tracy SK, Hartz DL, Tracy MB, Allen J, Forti A, Hall B, et al. Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial. Lancet 2013;382(9906):1723–32. 5. Walton C. The birthplace in England study: methods, findings and evaluation. Br J Midwifery 2012;20(1):22–7. 6. Buckley S. Undisturbed birth. Nature’s blueprint for ease and ecstasy. United States: Midwifery Today, Inc.; 2002: 19. 7. Fahy K. Power and the social construction of birth territory. In: Fahy KM, Foureur M, Hastie C, editors. Birth territory and midwifery guardianship: theory for practice, education, and research. Books for midwives. New York/Edinburgh: Butterworth, Heinemann, Elsevier; 2008. 8. Nolan M, Smith J. Women’s experiences of following advice to stay at home in early labour. Br J Midwifery 2010;18(5):286–91. 9. Walsh D. Subverting the assembly-line: childbirth in a free-standing birth centre. Soc Sci Med 2006;62(6):1330. 10. Walsh DJ. ‘Nesting’ and ‘Matrescence’ as distinctive features of a free-standing birth centre in the UK. Midwifery 2006;22(3):228–39. 11. Fahy KM, Parratt JA. Birth territory: a theory for midwifery practice. Women Birth: J Aust Coll Midwives 2006;19(2):45–50. 12. Stenglin M, Foureur M. Designing out the Fear Cascade to increase the likelihood of normal birth. Midwifery 2013;29(8):819–25. 13. Walsh TC. Exploring the effect of hospital admission on contraction patterns and labour outcomes using women’s perceptions of events. Midwifery 2009;25(3):242–52. 14. Foureur M. Creating birth space to enable undisturbed birth. Birth territory and midwifery guardianship: theory for practice, education, and research. Books for midwives. New York/Edinburgh: Butterworth, Heinemann, Elsevier; 2008. 15. Foureur M, Hunter M. Place of birth. Midwifery: preparation for practice. Elseiver Health Science APAC; 2011: 104–24.
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Please cite this article in press as: Townsend B, et al. The birth bed: A qualitative study on the views of midwives regarding the use of the bed in the birth space. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.08.009