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Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study
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WOMBI-431; No. of Pages 8 Women and Birth xxx (2015) xxx–xxx
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Women and Birth journal homepage: www.elsevier.com/locate/wombi
ORIGINAL RESEARCH – QUANTITATIVE AND QUALITATIVE
Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study Margareta Johansson a,*, Li Thies-Lagergren b a b
Department of Clinical Science and Education, Karolinska Institutet So¨dersjukhuset, SE-118 83 Stockholm, Sweden The Department of Health Sciences: Child, Family & Reproductive Health, Health Sciences Centre, Lund University, PO Box 157, S-221 00 Lund, Sweden
A R T I C L E I N F O
Article history: Received 16 April 2015 Received in revised form 21 May 2015 Accepted 15 June 2015 Keywords: Birth experience Birth position Fathers Mixed method Participation
A B S T R A C T
Background: Fathers often want to be involved in labour and birth. Aim: To investigate how maternal birth position during second stage of labour may influence fathers’ experience of childbirth. Methods: Mixed method study with 221 Swedish fathers completing an on-line questionnaire. Descriptive statistics and qualitative content analysis were used. Results: In total 174 (78.7%) had a positive overall birth experience. The theme An emotional life-changing event influenced by the birth process and the structure of obstetrical care was revealed and included the categories; Midwives ability to be professional, The birth process’ impact, and Being prepared to participate. The most frequently utilised birth position during a spontaneous vaginal birth was birth seat (n = 83; 45.1%), and the fathers in this group were more likely to assess the birth position as very positive (n = 40; 54.8%) compared to other upright and horizontal birth positions. Fathers with a partner having an upright birth position were more likely to have had a positive birth experience (p = 0.048), to have felt comfortable (p = 0.003) and powerful (p = 0.019) compared to women adopting a horizontal birth position during a spontaneous vaginal birth. When the women had an upright birth position the fathers deemed the second stage of labour to have been more rapid (mean VAS 7.01 vs. 4.53) compared to women in a horizontal birth position. Conclusion: An upright birth position enhances fathers’ experience of having been positively and actively engaged in the birth process. Midwives can enhance fathers’ feelings of involvement and participation by attentiveness through interaction and communicating skills. ß 2015 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
1. Introduction Since the late 1960s expectant fathers in Sweden have been encouraged to attend the birth of their children and currently the majority participate in the process of birth.1 Expectant fathers want to be authentically engaged during labour and birth,2 and their attendance has had a positive impact on the birth process and on labouring women’s birth experience.2,3 A support person being present for a woman in labour leads more often to a spontaneous vaginal birth, less need for
* Corresponding author at: Department of Clinical Science and Education, Karolinska Institutet So¨dersjukhuset, Sjukhusbacken 10, SE-118 83 Stockholm, Sweden. Tel.: +46 70 241 5275; fax: +46 8 616 20 89. E-mail addresses: [email protected], [email protected] (M. Johansson), [email protected] (L. Thies-Lagergren).
intrapartum pain relief, shortened duration of labour and a decreased risk of experiencing dissatisfaction.4 However, fathers have sometimes been discontented with their ability to support the woman during labour.5 Women tend and prefer to use a variety of positions during labour and birth.6 Mobility promotes optimal uterine perfusion, alignment of the foetal head in the pelvis and descent.7 It has been reported that women who articulated preferences for birth position ahead of birth were more likely to be in a preferred position at birth.8 The use of various positions is, however, facilitated or constrained by the policies and philosophy of the birth care environment.7 Upright positioning has been associated with reduction of labour pain and an increase in maternal satisfaction.9 Other obstetrical advantages of an upright position include shorter second stage, fewer episiotomies,10,11 and less use of synthetic oxytocin in the second stage of labour.11 Reports regarding
http://dx.doi.org/10.1016/j.wombi.2015.06.001
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: Johansson M, Thies-Lagergren L. Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.06.001
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reduction in assisted deliveries are inconclusive but fewer abnormal foetal heart rate patterns have been reported when mothers adopting an upright position at birth. Negative outcomes are described as a small increase in second-degree lacerations and excessive blood loss, almost exclusively in women who used birth chairs.10,12 As previous studies have reached consensus that a fathers attendance at birth has an important impact on maternal birth experience,3 as well as on his own birth experience,5,13 and on his bonding with the child,13 it is of importance to provide even more data on what makes the birth experience positive for expectant fathers. Birth position during second stage of labour is known to have an impact on women’s experiences, yet little is known about fathers’ experiences of birth position adopted by the woman. Fathers highlight the importance of being involved in decision-making on various aspects of care, and one of the decisions they want to contribute to may be to assist the woman in her choice of birth position.3 The aim of the present study was to investigate how maternal birth position during second stage of labour may influence fathers’ experience of childbirth. 2. Methods In order to describe and explore Swedish fathers’ birth experience in relation to maternal birth position in the second stage of labour, a mixed method strategy integrating quantitative and qualitative data was employed. The strategy of mixed method by collecting quantitative and qualitative data at the same point in time, and within the same group of participants facilitate findings and enhance a deeper understanding of fathers’ birth experience.14 This study was nestled within a randomised controlled trial (RCT), which randomised healthy nulliparous women to birth on a birth seat or in any other birth position.12 The recruitment for this follow-up study took place between 2010 and 2012, and respondents from two labour wards in the hospital’s catchment area were polled.
needed. The questionnaire included both closed-ended questions and a possibility to comment on the birth experience. It contained socio-demographic characteristics (age, marital status, level of education, country of birth and planned pregnancy) and items regarding mode of birth, experiences of birth and birth position. The birth position of birth seat, kneeling and standing were grouped and labelled into ‘upright birth position’; and semirecumbent, supine, lithotomy, left-lateral into ‘horizontal birth position’. The questions regarding experience of the labour duration and birth position adopted by their spouse at birth were measured on Visual Analogue Scales (VAS) ranging from 0 to 10. For the experience of the length of labour, 0 signified prolonged labour and 10 a rapid labour. For the experience of birth position, 0 signified a very negative and 10 a very positive experience, and was dichotomised into the categories ‘less positive’ (i.e. VAS 0–7) and ‘positive’ (i.e. VAS 8–10) due to mean 7.65 of this variable. Another question about the overall experience of birth could be answered according to a Likert scale from 1 to 5, where 1 denoted a very positive and 5 a very negative experience. This variable was dichotomised into the categories ‘positive birth experience’ (1–2) and ‘less positive birth experience’ (3–5) because of the skewedness of the answers. Respondents were also able to freely choose between any of five different positive expressions of emotions, which may have arisen in relation to the maternal birth position. They were free to check any number of emotions that were relevant to their experience in the questionnaire. The open-ended question was worded; ‘‘Please tell us in your own words about your birth experience’’. The responses varied from a single word to more elaborating sentences. The fathers’ comments were used to illustrate different quantitative aspects of their experience of birth position. 2.3. Outcome measurements Outcome measurements were experiences of birth and the spouse’s birth position. 2.4. Data analysis
2.1. Procedure and data collection All women who had participated in the RCT received a letter by post, which included an invitation to participate by submitting replies to an on-line questionnaire. In this letter a similar invitation to the woman’s partner was included. To be included in the study the partners had to be able to understand the Swedish language. The partner received a separate login address to the web based online questionnaire. The only thing that could connect the woman and her partner were that they had the same randomisation number making it possible to connect the partners. In the invitation letter comprehensive information was included about how collected materials would be processed under current confidentiality regulations. Participation in the study was voluntary and the prospective participant could at any time, without any particular explanation, terminate participation. A completed questionnaire was interpreted as informed consent. Two reminders were sent by E-mail with an interval of three weeks apart. Altogether 221 fathers responded to the questionnaire on-line. 2.2. The on-line questionnaire The on-line questionnaire was constructed for the purpose of this follow-up study. The questionnaire was pre-tested by seven fathers before an invitation for participation was distributed. These answers were not included in this study. The test-retest method was carried out to ensure that the questions were understandable,15 and only a few linguistic corrections were
To be able to explore the fathers’ experiences of birth position and overall birth experience quantitative and qualitative data were collected. For the quantitative data analysis descriptive statistical analysis and were used. The level of statistical significance was set to 0.05 which is a commonly used level and is considered being small enough to justify rejection of the null hypothesis. Differences in mean and standard deviation (sd) between upright or horizontal birth position and experience of length of labour and birth/length of second stage of labour were analysed with t-tests. Chi-square test and Fisher’s Exact Test were calculated for comparison between upright or horizontal birth position and overall birth experience, emotions and experiences of maternal birth position by using a method described by Mantel and Haenzel, cited in Rothman.16 All analyses were performed using PASW version 22 (Predictive Analytics Software Inc., Chicago, USA). Qualitative content analysis was used to further explore the fathers’ comments about their overall birth experience.17 The analysis closely adhered to the wordings in the comments. In order to interpret the data, each of the two authors (MJ and LT-L) read through all of the statements numerous times, separately, to obtain a sense of the whole.17 The statements were then divided into smaller parts, which all were labelled with different codes. Thereafter both authors grouped the codes, jointly, into seven created subcategories according to their common content. In the continuing analysis subcategories with similar events and incidents were grouped together into three categories and eventually one overriding theme, of which all included the meaning of the fathers’ birth experience.
Please cite this article in press as: Johansson M, Thies-Lagergren L. Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.06.001
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Theme
3
An emotional life-changing event influenced by the birth process and the structure of obstetrical care
Category
Midwives ability to be professional
Subcategories
Professionals’ attentiveness
Codes
Obstetrical competences
Organization of
of professionals
midwifery care
“…it's safe having a
“We had three different
“I´m a bit critical to
professional staff that
midwives and everyone
the sudden change of
support and encourage.
was very nice, competent
staff or team amidst
and supportive. They
childbirth, during the
were very different in
second stage of
their own way, but all
labour”
were very good”
Fig. 1. An example of the data analysis process for the qualitative data.
See Fig. 1 for an example of the data analysis process including one of the three categories. According Graneheim and Lundgren,17 the purpose of creating codes, categories and themes is to abstract condensed text into a higher level and thereby understand the phenomena of interest, and thereby develop new knowledge. The study was approved by the committee for research ethics in Lund, Sweden (Dnr 2009/739). 3. Results 3.1. Study participants In total, 221 fathers were included in this mixed-method study. They were more often aged 25–35 (n = 144, 65%), living with their spouse (n = 218, 99%), having an elementary or high school level of education (n = 115, 52%), had a planned pregnancy (n = 198, 90%) and of a Swedish origin (n = 207, 94%). Of the fathers’ spouses 184 (83%) had a spontaneous vaginal birth, 28 (13%) a delivery assisted with vacuum extraction and 9 (4%) an emergency caesarean section. Of the respondents, 49.8% (n = 110) fathers completed the qualitative portion by answering the open-ended question: ‘‘Please tell us in your own words about your birth experience’’. Of those fathers writing any comments 46.2% (n = 42) had a spouse who had given birth in an upright birth position and 52.3% (n = 68) had a spouse giving birth in a horizontal position (spontaneous vaginal birth, vacuum extraction or caesarean section). The qualitative analysis of the open-ended question revealed the theme An emotional life-changing event influenced by the birth process and the structure of obstetrical care which was based on three categories labelled as; ‘Midwives ability to be professional’, ‘The birth process’ impact’, and ‘Being prepared to participate’. 3.2. Midwives ability to be professional The first category ‘Midwives ability to be professional’ involved three sub-categories including professionals’ attentiveness, obstetrical competences of professionals and organisation of midwifery care. This category involved most of the comments made.
3.2.1. Professionals’ attentiveness Throughout the fathers’ portrayals, they emphasised the midwives’ attentiveness through interaction, communicating skills and being present in the labour room. They found it important to receive information about the birth process, which helped the fathers to enhance better support to their spouse. When they got sufficient and adequate information they were better able to handle the situation around birth, and they felt safe and secure about their spouse and the unborn baby. If they were given information from the midwives they wanted it to be presented at the proper time and the information should be clear and appropriate. Midwives’ attitudes and engagement were also described. Mostly fathers described midwives as nice and cheery, being responsive and supportive which made the fathers feel welcome and safe. The experience of security resonance well in following statements; ‘‘We had an amazing midwife who helped us and encouraged my wife, and made us feel safe’’, ‘‘But despite the heavy work load they had an encouraging and reassuring manner’’, and ‘‘Undoubtedly one feels helpless, but we had two fantastic midwives with whom we felt safe and secure’’. The quantitative data analysis also pointed out that 62% (n = 138) of the fathers felt safe and secure, this regardless of birth position and mode of birth. Yet, again some experienced the midwives being harsh, nonresponsive and unengaged, demonstrating an ungentle manner. Some of the more lengthy comments were when midwives were described in a negative manner; ‘‘I experienced the latter midwife as little unengaged. She ran on routine and had a practiced style and was not at all as responsive as the first one. I didn’t like her ‘‘harsh’’ approach’’, and ‘‘I felt I was in the way. I took the opportunity to ask when I managed to make eye contact with the midwife only then did I get the information I needed’’. The fathers described in positive sentences their experience of the midwives’ presence in the birthing room in ways such as; ‘‘. . . Luckily, the midwife student was continuously present in the room which was . . . pleasant’’ and ‘‘Good attendance and control on behalf of the midwife’’. On the other hand, when the midwives were spent only a limited time with the couple in the birthing room they said; ‘‘. . . We hardly met her [the midwife], only her student’’, ‘‘They were absent a lot; they were not so much with us’’, and ‘‘I noticed that the
Please cite this article in press as: Johansson M, Thies-Lagergren L. Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.06.001
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staff had much to do. They spent very little time in the room . . . during the first stage of labour’’.
Table 1 The fathers’ birth experiences and emotions in relation to maternal birth position.
x2
Spontaneous vaginal birth
3.2.2. Obstetrical competence of professionals The importance of professionalism was mentioned in the fathers’ portrayals. Expressions like experienced, skilled, competent, quick, and planning were mentioned several times. Some expressed that they received incredibly good help throughout the birth and they felt very comfortable and taken good care of by the skilled staff. The fathers felt that the midwives were in control of the situation, that the midwives knew when and how to act. This competence can be exemplified by ‘‘an experienced midwife who resolutely fashioned a sheet in a way that allowed it to be used in a tugof-war manner, giving my partner good leverage when pushing, which worked excellently in aiding the child’s birth’’. However, some fathers experienced the midwives as less experienced with, for example, a poor planning regarding painrelief; ‘‘No one listened to me and my wife, they did whatever they pleased without asking us, like suturing my wife without anesthesia’’. When the professionals were lacking obstetrical competence the fathers felt they had to be persistent and they felt insecure. 3.2.3. Organisation of midwifery care The fathers spontaneously commented on the organisation regarding midwifery care. The organisation concerning changing of staff during birth resulted in several comments. The fathers were critical to this, expressed feelings of insecurity and they did not have enough time to build a sense of trust towards the midwife who entered the room to assist the birth at the very end. The fathers described this as ‘‘It was really bad luck . . .’’, ‘‘I’m a bit critical of the sudden change of staff. . .’’, and ‘‘. . .the midwife who took over could unfortunately not build any confidence so it was not quite good in a security-sense at this time’’. On the other hand a change of staff could also be experienced as positive and improve the birth experience; ‘‘. . . but the midwife who took over, gave us all the confidence we needed’’. 3.3. The birth process’ impact The second category revealed in the qualitative data analysis was labelled ‘The birth process’ impact’ and involved two subcategories, which were labelled as ‘Overall experience of the birth process’ and ‘An upright birth position was mostly regarded as positive’. 3.3.1. Overall experience of the birth process In total 174 (78.7%) had a positive overall birth experience. The fathers were more likely to have had experienced the birth as an overall positive event, this revealed both in the quantitative and qualitative data analysis. Some examples of positive statements were; ‘‘It’s a very cosy, nice and incredible experience’’, ‘‘. . .Absolutely fantastic’’ and ‘‘A powerful and positive experience’’. Important issues for strain related to the overall birth experience were when the spouse had a horizontal birth position, instrumental birth, prolonged time for the process of labour and birth, labour pain and if complications for the spouse and/or the new-born child arose. Those who had a spouse with an upright birth position during a spontaneous vaginal birth were significantly more likely to have a positive birth experience compared to those having a spouse adopted a horizontal birth position (r = 0.048) (Table 1). The fathers who had a spouse delivered by vacuum extraction were more likely to have a positive birth experience compared to emergency caesarean section (n = 20, 71% vs. n = 1, 11%; r = 0.003). Fathers with a spouse delivered by emergency caesarean section described the event as ‘‘a traumatic experience’’ and ‘‘the most horrible, but still the best experience of my life’’. When their child was born by vacuum extraction some fathers expressed that as a
Upright
a
b
Horizontal
p-Value
n = 91
n = 93
n (%)
n (%)
81 (89.0) 10 (11.0)
72 (77.4) 21 (22.6)
0.048
Emotions free to chose from for the spouse’s birth position Safe and secure (Yes) 60 (65.9) 55 (59.1) Comfortable (Yes) 50 (54.9) 31 (33.3) Relaxed (Yes) 24 (26.4) 16 (16.1) Strong (Yes) 23 (25.3) 15 (16.1) Powerful (Yes) 19 (20.9) 8 (8.6)
0.341 0.003 0.132 0.125 0.019
Overall birth experience Positive Less than positive
Experiences of the spouse’s birth position assessed by Visual Analogue Scalec 0 till 7 20 (22.0) 39 (41.9) 71 (78.0) 54 (58.1) 0.005 8 till 10 a b c
Birth seat, kneeling and standing birth position. Semi-recumbent, supine, lithotomy, left-lateral birth position. Visual Analogue Scale 0 = Very negative, 10 = Very positive.
stressful experience but they were ‘‘grateful for the child coming the natural way’’, and ‘‘that was fine with all the support from all the professionals . . .’’. The quantitative data analysis pointed out that 80% (n = 177) of the fathers were not relaxed during the spouse’s second stage of labour this regardless of mode of birth. However, there were no statistical differences between fathers’ emotion of being relaxed if the spouse had an upright or horizontal birth position during a spontaneous vaginal birth (Table 1). The aspect of time was expressed with great variation. When the birth process was experienced as quick and rapid they regarded it as positive, good and smooth, one father expressed this like; ‘‘The birth was significantly faster and more straightforward than expected, which must be regarded as positive’’. However, one father regarded the rapid pace as negative when it caused limited time for discussions. In the quantitative data analysis it became evident that fathers who experienced their spouse giving birth in an upright position, were more likely to have had experienced the birth being more rapid (mean VAS 6.31 vs. 4.41), and judged the second stage of labour more rapid (mean VAS 7.01 vs. 4.53) compared to women having a horizontal birth position during a spontaneous vaginal birth (Table 2). When the process of birth was regarded as going on well, flowing calmly or at an appropriate pace they experienced the labour process as very smooth. When the process of labour on the contrary was long and slow, feelings of helplessness, anxiousness, confusion, tiredness, feeling less positive and being upset were aroused. One father whose child was born by vacuum extraction expressed; ‘‘It was a difficult birth
Table 2 The fathers’ experiences of length of childbirth in relation to maternal birth position.
Assessed by Visual Analogue Scale (VAS)c for Experience of length of labour and birth Experience of length of second stage of labour a b c
Spontaneous vaginal birth
t-Test
Uprighta
Horizontalb
p-Value
n = 91
n = 93
Mean (sd)
Mean (sd)
6.31 (2.78)
4.41 (3.40)
<0.001
7.01 (2.50)
4.53 (3.37)
<0.001
Birth seat, kneeling and standing birth position. Semi-recumbent, supine, lithotomy, left-lateral birth position. VAS 0 = prolonged, 10 = rapid.
Please cite this article in press as: Johansson M, Thies-Lagergren L. Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.06.001
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because it took a very long time and eventually became critical’’. Another father explained; ‘‘It took longer time than I thought; I felt that the staff was a little worried when it took longer than they thought. They kept telling me that now it’s not far away, then another 3 hours passed. This made me worried for the sake of my girlfriend and child.’’ Labour pain caused the fathers to feel helpless, strained, tense, nervous, and uncomfortable. Comments like; ‘‘It affected me negatively and I could not do anything’’, and ‘‘. . . my wife was in great pain but I couldn’t do anything about it’’ were described by the fathers. One father was feeling powerless despite acknowledging his wife strength and his ability to support his wife. ‘‘It was difficult to see how my wife suffered; I gave her all the support I could, but still felt powerless because I could not take the pain upon me. She was so strong, stronger than ever.’’ In case of complications for the spouse and/or the new-born child it caused strain for the fathers. Some experienced labour dystocia being very stressful, other expressed that severe perineal trauma was laborious. Some expressed fear of death when the spouse lost blood after birth and a frightening situation was also when the new-born child needed resuscitation which illustrates in; ‘‘Some complications arose when the baby came out and it was quite traumatizing. The child’s breathing was not working properly’’. 3.3.2. An upright birth position was mostly regarded as positive Most common maternal birth position during a spontaneous vaginal birth was birth seat (n = 83; 45.1%) (Table 3), and the fathers in this group were more likely to assess the birth position as very positive, i.e. VAS 10 (n = 40; 54.8%) compared to other upright and horizontal birth positions. Most common birth position during a spontaneous vaginal birth with a horizontal birth position was lithotomy (n = 30; 32.2%) (Table 3), approximately one third of these fathers assessed the birth position as very positive, i.e. VAS 10. The fathers with a spouse having a spontaneous vaginal birth were more likely to judge an upright birth position as positive (VAS 8–10) compared to a horizontal birth position (r = 0.005) (Table 1). The aspect of being comfortable was pointed out in the quantitative data analysis as 40.3% (n = 89) of the fathers experiencing being comfortable during the second stage of labour, this regardless of birth mode. The fathers with a spouse having an upright position were more likely to have felt comfortable compared to those whose spouse was in a horizontal birth position during a spontaneous vaginal birth (r = 0.003) (Table 1). This finding was corroborated in the qualitative data analysis as; ‘‘She tested various positions, but the birth seat was the most comfortable. It was also the one that I liked the most’’. On the contrary when not feeling comfortable one father explained; ‘‘The only time that I felt uncomfortable was during the very last part of the second stage of labour then it seemed to hurt incredibly much’’.
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The fathers were also more likely to experience the birth as powerful when the spouse was in an upright birth position during a spontaneous vaginal birth this compared to a horizontal birth position (r = 0.019) (Table 1). The issue of power was described in the quotes as; ‘‘I wonder if we got a little more lacerations since we felt a very satisfying surge of power during the second stage of labour . . ., but as I said, we were contented.’’ Solely fathers who had experienced their spouse giving birth on a birth seat commented on their own experiences regarding birth position during the second stage of labour. The experiences were described as ‘‘the birth seat enhanced birth becoming a fantastic experience’’; ‘‘. . . my wife had not made it without the birth seat’’ and ‘‘. . . the birth seat was very helpful and it became a more natural position to give birth in . . .’’. Several fathers recommended this birth position to other couples. However, a couple of fathers did not find the birth seat being a good option or were disappointed with the birth seat; ‘‘. . . the birth seat did not work as we had hoped it would’’ and ‘‘. . . my wife could not positioning herself in a comfortable way’’. Of the fathers who had a spouse in a birth seat position 20.5% (n = 17) assessed the position as VAS 0–7 (Table 3). This negative experience was described as; ‘‘. . .the midwife was not so used to assist how to sit on [the birth seat]. How I should sit was improvised, and the chair I was sitting on had no cushion. A pillow to have between me and her back was forgotten. Once we sat down my wife could not reach the oxygen mask so we had to move . . . So I felt she [the midwife] was a little bit in-experienced and had not fully track of how to support a birthing woman on a birth seat’’. 3.4. Being prepared to participate The third category was labelled ‘Being prepared to participate’ and involved two subcategories, which emphasised the importance of being prepared for labour and birth, and to participate in the process of birth. The fathers described preparation with breathing and relaxing techniques and reading literature which helped them feel safe and in control. If the preparation was lacking, they felt, on the contrary, lost, pressed and did not know what to expect as well as not knowing what might be more or less helpful. In spite of preparation activities some fathers pointed out labour and birth as something new, hard to imagine in beforehand, nothing one could imagine or being in an unknown territory. One father said he felt unprepared for the birth event and he was the one to blame. Birth preparation with breathing and relaxing techniques and professionals who introduced them to techniques in how to support the spouse during labour made the fathers involved and they experienced that they could contribute with protection and coaching. When they experienced participation they felt it fantastic. Many fathers described feelings of weakness, fear, intensity, apathy, being in an own ‘bubble’, this consequently leading to
Table 3 Fathers’ experience of maternal birth position by Visual Analogue Scale (VAS). Spontaneous vaginal birth Horizontal birth positionb n = 93
Upright birth position n = 91 Birth seat
Kneeling
Standing
Lithotomy
Supine
Semi-recumbent
Left-lateral
n = 83
n=6
n=2
n = 30
n = 29
n = 25
n=9
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
1 (50.0) 1 (50.0)
10 (33.3) 20 (66.7)
10 (34.5) 19 (65.5)
12 (48.0) 13 (52.0)
4 (44.4) 5 (55.6)
Experiences of partner’s birth position by VASa 0–7 17 (20.5) 2 (33.3) 8–10 66 (79.5) 4 (66.7) a b
0 = very negative, 10 = very positive. Horizontal birth position with exclusion for vacuum extraction and caesarean section.
Please cite this article in press as: Johansson M, Thies-Lagergren L. Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.06.001
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difficulties in realizing their role in supporting the spouse. They felt they should have stood up for their partner even more but they did not have any impact over the birth process. One father expressed; ‘‘I was the most unnecessary part of the birth. The feeling I got in the room was that I wanted to go away, but I did not want to miss the moment when my child was born. The fathers should be included in a more inviting way.’’ Some fathers had wanted to be more involved. They felt that the midwives should have been more active involving them in the birth process; that the fathers ought to be involved. One father said that he felt that the midwife did not find that becoming a father was important. However, fathers whose partner gave birth on the birth seat expressed feelings of participation; ‘‘Because my wife had her arms on my legs like arm-rests, I felt involved and I don’t think I should have done so if I had been standing beside her. To really get to know how much power there is behind giving birth to a baby was fantastic . . . Afterwards, I got a feeling that I also had been giving birth.’’ ‘‘As a father, sitting behind my beloved and being able to participate through the entire birth was very important for me.’’ 4. Discussion This study is unique as it, to the best of the authors’ knowledge, probably is the first paper of its kind to describe and explore fathers’ experience of their spouse’s birth position in the second stage of labour. It contributes to the growing body of literature about fathers’ experiences of childbirth. The findings of this study revealed that eight out of ten fathers had a positive overall birth experience. Those with a spouse who had given birth in an upright birth position were more likely to have had a positive overall birth experience, to feel comfortable and powerful compared to those who had a partner who adopted a horizontal birth position. When the spouses had had an upright birth position the fathers experienced a shorter birth compared to spouses having a horizontal birth position. A positive birth experience among fathers was related to midwives ability to be professional and to be prepared for participation in labour and birth. 4.1. The impact of an upright birth position In most cultures, birthing in a bed is regarded as customary and expected by both parents-to-be and for birth attendees.7 The preferences for birth positions and the philosophies of professionals have an impact upon positions that women adopt during birth.9 The fathers in this study had a more overall positive birth experience when the spouse had an upright position in the second stage of labour compared to fathers who had an experience of a horizontal position. This is concurrent with the only study identified describing fathers’ experience regarding birth position.18 The advice of birthing position given by midwives during the second stage of labour has influenced the women’s preference of birthing positions. Other sources that influence the positions are midwives’ information during antenatal classes and other women’s stories.6 Freedom to change positions in labour has been identified as integral to a feeling of control and the management of pain in labour, due to the physical and psychological benefits. To feel in control has been experienced when women are able to choose the most comfortable birth position.9,19 Issues related to women’s sense of control during the second stage of labour have been influenced on adopted birth position (self or self together with others) and labour pain. The negative effect of labour pain was less in multiparous women than in primiparous women.20 Women
have described being in more control over their pushing in the second stage when they were in an upright position compared to a supine position.6 In this study the birth seat position gave the fathers feelings of being comfortable and powerful. The fathers were more likely to experience the birth as more rapid when the woman adopted an upright birth position. When the birth process was experienced as quick, smooth and rapid they regarded it as positive. Advantages of an upright position include shorter second stage of labour.7,9,10,12 Any upright or lateral birth positions compared with supine or lithotomy positions have been associated with reduced duration of second stage of labour.10 A fast progress of labour has given multiparous women an increased feeling of control,19 and in this study the fathers regarded a rapid labour process as positive and good. 4.2. Midwives ability to be professional The fathers emphasised in this study the importance of midwives’ attentiveness through interaction and communicating skills for their birth experience. To receive information about the birth process was vital. When given sufficient and adequate information they were better able to handle the situation, and they felt safe and secure. The quality of midwives communication and interaction with expectant fathers had a big impact upon men’s level of engagement and their active involvement in the process of birth. Respectful behaviour and language on the part of the professionals have had an impact on fathers’ sense of involvement. Fathers working in partnership with the midwife have been described as a factor leading to better being able to support the woman. The fathers then felt that they were being of use to their woman.5 In a Swedish interview study it became evident that the team of professionals in case of a caesarean section played a key role for fathers’ birth experience. Important aspects of a positive experience were the professionals’ ability to share information, as well as their attitudes and behaviour. The fathers valued when the staff spoke with them, explained and kept them ‘up to date’.21 Lack of designated information for expectant fathers during labour and birth has furthermore been related to feelings of distress and a less positive birth experience.5,22 The importance of professional obstetrical competence was also mentioned in the fathers’ portrayals. A less positive birth experience on the part of fathers has previously been related to questions as to whether the woman was receiving the best possible medical care, if the extent of the midwife’s presence in the birthing room was as desired, with the midwife giving the support needed. On the other hand, when fathers had perceived that the professionals were making adequate decisions during labour and birth, feelings of a wonderful and fantastic experience ensured, leading to satisfaction with care provided.22 4.3. Being prepared to participate Feeling prepared for labour and birth gave the fathers a sense of safety and control in the unknown process of childbirth explored by this study. Fathers often want to participate and to be involved in the care of their female partner during labour and birth. This involvement also has a positive impact on their experience of the birth of their child.5,22 Fathers have previously recognised birth as a unique event that may be potentially challenging requiring a level of preparation. For first time fathers childbirth has been regarded as an unknown territory. Because of that, men’s mental and physical preparation was important for their ability to be actively involved in the labour and birth of their child. When a feeling of being prepared was lacking the fathers were more likely to feel out of control and could not support the woman in the birth
Please cite this article in press as: Johansson M, Thies-Lagergren L. Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.06.001
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process.5 In this study fathers having a spouse who had a birth seat position expressed feelings of participation through this birth position. In a Dutch qualitative study it was reported that from a maternal point of view the father rarely influenced the choice of position and their support for a specific position was not an important factor.6 But, if the birthing woman has an influence on the birthing position together with others, such as the midwife or the expectant father then this has been related to a higher sense of control than when having such an influence only by themselves.20 In an RCT from Sweden regarding birth position in the second stage of labour, it was reported that expectant fathers in the experimental group (birth seat) felt more supportive, more involved and more satisfied with their own contribution during the second stage of labour than expectant fathers in the control group (supine position).18 Being in an upright position in the second stage of labour makes both fathers and birthing women feel more involved in the birth process.23 It can be assumed that fathers experiencing birth in an upright position will make them feel more authentically engaged and supportive. In order to facilitate a positive birth experience for fathers, midwives must include them in conversations and in the support and care for the woman.24 Fathers often feel that they are able to support their labouring spouse to some extent. They could give back massage,6,25 more easily when the women adopt a birthing stool position.6 It was also easier to help her change her position during labour.25 The support person is also known to frequently imitate the professional caregiver’s instructions during the second stage of labour.26 Women’s perception of feeling supported during labour can alter the perception of pain, allowing women to respond instinctively in labour, and lead to ultimate feelings of satisfaction with the birthing process. Women require unrestricted access to their choice of support people, continuous emotional and physical support from a skilled woman and continuous midwifery care, which is seen to result in increased satisfaction.9 4.4. Methodological considerations and limitations Several limitations should be discussed. Initially 1002 male partners to the included participants of women in the original RCT,12 were invited to this follow up-study. Approximately 22% responded, a relatively low response rate, which must be taken into consideration when interpreting the findings, and generalizability of the study may be limited. The collection of data was, for some respondents, delayed for as long as four years as became apparent once the analysis of the original RCT was complete, thus it became necessary to carry out a follow-up study. This relatively long time-span between birth of their child and receiving the questionnaire may also have caused the low response rate. Previous research has suggested that women’s memories of childbirth are generally accurate, even years later,27 which probably apply for fathers as well. No literature regarding fathers’ long-time perception or memory of childbirth has been identified, however it has been suggested that individual’s memories of birth experiences are accurate and will remain consistent over a long period of time when being personally involved.28 Furthermore, fathers were not questioned on the subject of having any previous children which is a limitation within this study. However, only nulliparous women were included in the original RCT, and therefore the fathers perhaps were more likely to be first time fathers. The fathers were asked to write down their overall experience of the birth in their own words; they were not specifically asked to express their experiences of maternal birth position during the second stage of labour. This probably resulted in lack of information regarding their explicit experience of the actual birth position. However, the fathers who had experienced the birth seat were the only ones who specifically commented on the birth
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position and it can therefore be assumed that this birth position had an impact on the overall birth experience. This assumption is in line also with results reported by Waldenstro¨m and Gottvall.18 The abstraction in the content analysis was restricted by the limited content of the comments. The use of the mixed-method approach applied in this study may prove additional strength as the qualitative data helped validate the quantitative ones, to amplify and give a more personal insight into the fathers’ experience of the birth position their spouse adopted in the second stage of labour.14 4.5. Conclusion This mixed-method study contributes with more data on what makes the birth experience positive for expecting fathers. The study revealed that an upright position in the second stage of labour, in particular when a birth seat is facilitated, enhances fathers’ feelings of being actively engaged in the birth process. In addition the upright position made the fathers feel comfortable and powerful. Midwives can enhance fathers’ feelings of involvement and participation by attentiveness through interaction and communicating skills. Acknowledgements and disclosures This study was supported by grants from the Stig and Ragna Gorthon Foundation, Selma Zoega’s Foundation and professor emeritus Vivian Wahlberg’s fund which we gratefully acknowledge. Our thanks also go to all fathers who willingly responded to the on-line questionnaire reported in this article, and to Sara Ingero¨ who gave helpful advice on the language editing. The authors have no disclosures to report. References 1. Green J, Amis D, Hotelling BA. Care practice #3: continuous labor support. J Perinat Educ 2007;16(3):25–8. 2. Plantin A, Olukoya AA, Ny P. Positive health outcomes of fathers’ involvement in pregnancy and childbirth. Paternal support: a scope study literature review. Fathering 2011;9(1):87–102. 3. Lavender T, Walkinshaw SA, Walton I. A prospective study of women’s views of factors contributing to a positive birth experience. Midwifery 1999;15(1):40–6. 4. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2013;15(7):CD003766. [Epub ahead of print]. 5. Johansson M, Fenwick J, Premberg A˚.. A meta-synthesis of fathers’ experiences of their partner’s labour and the birth of their baby. Midwifery 2015;31(1):9–18. 6. De Jonge A, Lagro-Janssen AL. Birthing positions. A qualitative study into the views of women about various birthing positions. J Psychosom Obstet Gynaecol 2004;25(1):47–55. 7. Roberts JE. The ‘‘push’’ for evidence: management of the second stage. J Midwifery Womens Health 2002;47(1):2–15. 8. Thies-Lagergren L. The Swedish birth seat trial (thesis). Stockholm; 2013. Available at: http://www.helsingborgslasarett.se/download/18.1859dfd713 ef5dbab6b193/1370003381188/Thies-Lagergren+Li.pdf [accessed 11.04.15]. 9. Priddis H, Dahlen H, Schmied V. What are the facilitators, inhibitors, and implications of birth positioning? A review of the literature. Women Birth 2012;25(3):100–6. 10. Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev 2012;16(5.). Art. No.: CD002006 [accessed 11.04.15]. 11. Thies-Lagergren L, Kvist LJ, Christensson K, Hildingsson I. Striving for scientific stringency: a re-analysis of a randomised controlled trial considering first-time mothers’ obstetric outcomes in relation to birth position. BMC Pregnancy Childbirth 2012;12:135. 12. Thies-Lagergren L, Kvist LJ, Christensson K, Hildingsson I. No reduction in instrumental vaginal births and no increased risk for adverse perineal outcome in nulliparous women giving birth on a birth seat: results of a Swedish randomized controlled trial. BMC Pregnancy Childbirth 2011;11:22. 13. Erlandsson K, Lindgren H. From belonging to belonging through a blessed moment of love for a child – the birth of a child from the fathers’ perspective. J Mens Health 2009;6(4):338–44. ¨ stlund U, Kidd L, Wengstro¨m Y, Rowa-Dewar N. Combining qualitative and 14. O quantitative research within mixed method research designs: a methodological review. Int J Nurs Stud 2011;48(3):369–83.
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15. Streiner DL, Norman GR. Health measurement scales: a practical guide to their development and use. Oxford: Oxford University Press; 2008. 16. Rothman KJ. Epidemiology: an introduction. New York, NY: Oxford University Press; 2012. 17. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004;24(2):105–12. 18. Waldenstro¨m U, Gottvall K. A randomized trial of birthing stool or conventional semirecumbent position for second-stage labor. Birth 1991;18(1):5–10. 19. Green JM, Baston HA. Feeling in control during labor: concepts, correlates, and consequences. Birth 2003;30(4):235–47. 20. Nieuwenhuijze MJ, de Jonge A, Korstjens I, Bude L, Lagro-Janssen TL. Influence on birthing positions affects women’s sense of control in second stage of labour. Midwifery 2013;29(11):e107–14. 21. Johansson M, Hildingsson I, Fenwick J. Important factors working to mediate Swedish fathers’ experiences of a caesarean section. Midwifery 2013;29(9): 1041–9.
22. Johansson M, Rubertsson C, Radestad I, Hildingsson I. Childbirth – an emotionally demanding experience for fathers. Sex Reprod Healthc 2012;3(1):11–20. 23. Thies-Lagergren L, Hildingsson I, Christensson K, Kvist LJ. Who decides the position for birth? A follow-up study of a randomised controlled trial. Women Birth 2013;26(4):e99–104. 24. Hildingsson I, Cederlo¨f L, Wide´n S. Fathers’ birth experience in relation to midwifery care. Women Birth 2011;24(3):129–36. 25. Sapkota S, Kobayashi T, Takase M. Husbands’ experiences of supporting their wives during childbirth in Nepal. Midwifery 2012;28(1):45–51. 26. Roberts JM, Gonzalez CB, Sampselle C. Why do supportive birth attendants become directive of maternal bearing-down efforts in second-stage labor? J Midwifery Womens Health 2007;52(2):134–41. 27. Simkin P. Just another day in a woman’s life? Women’s long-term perceptions of their first birth experience. Part I. Birth 1991;18(4):203–10. 28. Lundqvist A, Nilstun T, Dykes A-K. Both empowered and powerless: mothers’ experiences of professional care when their newborn dies. Birth 2002;29(3): 192–9.
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Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
ORIGINAL RESEARCH – QUANTITATIVE AND QUALITATIVE
Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study Margareta Johansson a,*, Li Thies-Lagergren b a b
Department of Clinical Science and Education, Karolinska Institutet So¨dersjukhuset, SE-118 83 Stockholm, Sweden The Department of Health Sciences: Child, Family & Reproductive Health, Health Sciences Centre, Lund University, PO Box 157, S-221 00 Lund, Sweden
A R T I C L E I N F O
Article history: Received 16 April 2015 Received in revised form 21 May 2015 Accepted 15 June 2015 Keywords: Birth experience Birth position Fathers Mixed method Participation
A B S T R A C T
Background: Fathers often want to be involved in labour and birth. Aim: To investigate how maternal birth position during second stage of labour may influence fathers’ experience of childbirth. Methods: Mixed method study with 221 Swedish fathers completing an on-line questionnaire. Descriptive statistics and qualitative content analysis were used. Results: In total 174 (78.7%) had a positive overall birth experience. The theme An emotional life-changing event influenced by the birth process and the structure of obstetrical care was revealed and included the categories; Midwives ability to be professional, The birth process’ impact, and Being prepared to participate. The most frequently utilised birth position during a spontaneous vaginal birth was birth seat (n = 83; 45.1%), and the fathers in this group were more likely to assess the birth position as very positive (n = 40; 54.8%) compared to other upright and horizontal birth positions. Fathers with a partner having an upright birth position were more likely to have had a positive birth experience (p = 0.048), to have felt comfortable (p = 0.003) and powerful (p = 0.019) compared to women adopting a horizontal birth position during a spontaneous vaginal birth. When the women had an upright birth position the fathers deemed the second stage of labour to have been more rapid (mean VAS 7.01 vs. 4.53) compared to women in a horizontal birth position. Conclusion: An upright birth position enhances fathers’ experience of having been positively and actively engaged in the birth process. Midwives can enhance fathers’ feelings of involvement and participation by attentiveness through interaction and communicating skills. ß 2015 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
1. Introduction Since the late 1960s expectant fathers in Sweden have been encouraged to attend the birth of their children and currently the majority participate in the process of birth.1 Expectant fathers want to be authentically engaged during labour and birth,2 and their attendance has had a positive impact on the birth process and on labouring women’s birth experience.2,3 A support person being present for a woman in labour leads more often to a spontaneous vaginal birth, less need for
* Corresponding author at: Department of Clinical Science and Education, Karolinska Institutet So¨dersjukhuset, Sjukhusbacken 10, SE-118 83 Stockholm, Sweden. Tel.: +46 70 241 5275; fax: +46 8 616 20 89. E-mail addresses: [email protected], [email protected] (M. Johansson), [email protected] (L. Thies-Lagergren).
intrapartum pain relief, shortened duration of labour and a decreased risk of experiencing dissatisfaction.4 However, fathers have sometimes been discontented with their ability to support the woman during labour.5 Women tend and prefer to use a variety of positions during labour and birth.6 Mobility promotes optimal uterine perfusion, alignment of the foetal head in the pelvis and descent.7 It has been reported that women who articulated preferences for birth position ahead of birth were more likely to be in a preferred position at birth.8 The use of various positions is, however, facilitated or constrained by the policies and philosophy of the birth care environment.7 Upright positioning has been associated with reduction of labour pain and an increase in maternal satisfaction.9 Other obstetrical advantages of an upright position include shorter second stage, fewer episiotomies,10,11 and less use of synthetic oxytocin in the second stage of labour.11 Reports regarding
http://dx.doi.org/10.1016/j.wombi.2015.06.001
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: Johansson M, Thies-Lagergren L. Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.06.001
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reduction in assisted deliveries are inconclusive but fewer abnormal foetal heart rate patterns have been reported when mothers adopting an upright position at birth. Negative outcomes are described as a small increase in second-degree lacerations and excessive blood loss, almost exclusively in women who used birth chairs.10,12 As previous studies have reached consensus that a fathers attendance at birth has an important impact on maternal birth experience,3 as well as on his own birth experience,5,13 and on his bonding with the child,13 it is of importance to provide even more data on what makes the birth experience positive for expectant fathers. Birth position during second stage of labour is known to have an impact on women’s experiences, yet little is known about fathers’ experiences of birth position adopted by the woman. Fathers highlight the importance of being involved in decision-making on various aspects of care, and one of the decisions they want to contribute to may be to assist the woman in her choice of birth position.3 The aim of the present study was to investigate how maternal birth position during second stage of labour may influence fathers’ experience of childbirth. 2. Methods In order to describe and explore Swedish fathers’ birth experience in relation to maternal birth position in the second stage of labour, a mixed method strategy integrating quantitative and qualitative data was employed. The strategy of mixed method by collecting quantitative and qualitative data at the same point in time, and within the same group of participants facilitate findings and enhance a deeper understanding of fathers’ birth experience.14 This study was nestled within a randomised controlled trial (RCT), which randomised healthy nulliparous women to birth on a birth seat or in any other birth position.12 The recruitment for this follow-up study took place between 2010 and 2012, and respondents from two labour wards in the hospital’s catchment area were polled.
needed. The questionnaire included both closed-ended questions and a possibility to comment on the birth experience. It contained socio-demographic characteristics (age, marital status, level of education, country of birth and planned pregnancy) and items regarding mode of birth, experiences of birth and birth position. The birth position of birth seat, kneeling and standing were grouped and labelled into ‘upright birth position’; and semirecumbent, supine, lithotomy, left-lateral into ‘horizontal birth position’. The questions regarding experience of the labour duration and birth position adopted by their spouse at birth were measured on Visual Analogue Scales (VAS) ranging from 0 to 10. For the experience of the length of labour, 0 signified prolonged labour and 10 a rapid labour. For the experience of birth position, 0 signified a very negative and 10 a very positive experience, and was dichotomised into the categories ‘less positive’ (i.e. VAS 0–7) and ‘positive’ (i.e. VAS 8–10) due to mean 7.65 of this variable. Another question about the overall experience of birth could be answered according to a Likert scale from 1 to 5, where 1 denoted a very positive and 5 a very negative experience. This variable was dichotomised into the categories ‘positive birth experience’ (1–2) and ‘less positive birth experience’ (3–5) because of the skewedness of the answers. Respondents were also able to freely choose between any of five different positive expressions of emotions, which may have arisen in relation to the maternal birth position. They were free to check any number of emotions that were relevant to their experience in the questionnaire. The open-ended question was worded; ‘‘Please tell us in your own words about your birth experience’’. The responses varied from a single word to more elaborating sentences. The fathers’ comments were used to illustrate different quantitative aspects of their experience of birth position. 2.3. Outcome measurements Outcome measurements were experiences of birth and the spouse’s birth position. 2.4. Data analysis
2.1. Procedure and data collection All women who had participated in the RCT received a letter by post, which included an invitation to participate by submitting replies to an on-line questionnaire. In this letter a similar invitation to the woman’s partner was included. To be included in the study the partners had to be able to understand the Swedish language. The partner received a separate login address to the web based online questionnaire. The only thing that could connect the woman and her partner were that they had the same randomisation number making it possible to connect the partners. In the invitation letter comprehensive information was included about how collected materials would be processed under current confidentiality regulations. Participation in the study was voluntary and the prospective participant could at any time, without any particular explanation, terminate participation. A completed questionnaire was interpreted as informed consent. Two reminders were sent by E-mail with an interval of three weeks apart. Altogether 221 fathers responded to the questionnaire on-line. 2.2. The on-line questionnaire The on-line questionnaire was constructed for the purpose of this follow-up study. The questionnaire was pre-tested by seven fathers before an invitation for participation was distributed. These answers were not included in this study. The test-retest method was carried out to ensure that the questions were understandable,15 and only a few linguistic corrections were
To be able to explore the fathers’ experiences of birth position and overall birth experience quantitative and qualitative data were collected. For the quantitative data analysis descriptive statistical analysis and were used. The level of statistical significance was set to 0.05 which is a commonly used level and is considered being small enough to justify rejection of the null hypothesis. Differences in mean and standard deviation (sd) between upright or horizontal birth position and experience of length of labour and birth/length of second stage of labour were analysed with t-tests. Chi-square test and Fisher’s Exact Test were calculated for comparison between upright or horizontal birth position and overall birth experience, emotions and experiences of maternal birth position by using a method described by Mantel and Haenzel, cited in Rothman.16 All analyses were performed using PASW version 22 (Predictive Analytics Software Inc., Chicago, USA). Qualitative content analysis was used to further explore the fathers’ comments about their overall birth experience.17 The analysis closely adhered to the wordings in the comments. In order to interpret the data, each of the two authors (MJ and LT-L) read through all of the statements numerous times, separately, to obtain a sense of the whole.17 The statements were then divided into smaller parts, which all were labelled with different codes. Thereafter both authors grouped the codes, jointly, into seven created subcategories according to their common content. In the continuing analysis subcategories with similar events and incidents were grouped together into three categories and eventually one overriding theme, of which all included the meaning of the fathers’ birth experience.
Please cite this article in press as: Johansson M, Thies-Lagergren L. Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.06.001
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Theme
3
An emotional life-changing event influenced by the birth process and the structure of obstetrical care
Category
Midwives ability to be professional
Subcategories
Professionals’ attentiveness
Codes
Obstetrical competences
Organization of
of professionals
midwifery care
“…it's safe having a
“We had three different
“I´m a bit critical to
professional staff that
midwives and everyone
the sudden change of
support and encourage.
was very nice, competent
staff or team amidst
and supportive. They
childbirth, during the
were very different in
second stage of
their own way, but all
labour”
were very good”
Fig. 1. An example of the data analysis process for the qualitative data.
See Fig. 1 for an example of the data analysis process including one of the three categories. According Graneheim and Lundgren,17 the purpose of creating codes, categories and themes is to abstract condensed text into a higher level and thereby understand the phenomena of interest, and thereby develop new knowledge. The study was approved by the committee for research ethics in Lund, Sweden (Dnr 2009/739). 3. Results 3.1. Study participants In total, 221 fathers were included in this mixed-method study. They were more often aged 25–35 (n = 144, 65%), living with their spouse (n = 218, 99%), having an elementary or high school level of education (n = 115, 52%), had a planned pregnancy (n = 198, 90%) and of a Swedish origin (n = 207, 94%). Of the fathers’ spouses 184 (83%) had a spontaneous vaginal birth, 28 (13%) a delivery assisted with vacuum extraction and 9 (4%) an emergency caesarean section. Of the respondents, 49.8% (n = 110) fathers completed the qualitative portion by answering the open-ended question: ‘‘Please tell us in your own words about your birth experience’’. Of those fathers writing any comments 46.2% (n = 42) had a spouse who had given birth in an upright birth position and 52.3% (n = 68) had a spouse giving birth in a horizontal position (spontaneous vaginal birth, vacuum extraction or caesarean section). The qualitative analysis of the open-ended question revealed the theme An emotional life-changing event influenced by the birth process and the structure of obstetrical care which was based on three categories labelled as; ‘Midwives ability to be professional’, ‘The birth process’ impact’, and ‘Being prepared to participate’. 3.2. Midwives ability to be professional The first category ‘Midwives ability to be professional’ involved three sub-categories including professionals’ attentiveness, obstetrical competences of professionals and organisation of midwifery care. This category involved most of the comments made.
3.2.1. Professionals’ attentiveness Throughout the fathers’ portrayals, they emphasised the midwives’ attentiveness through interaction, communicating skills and being present in the labour room. They found it important to receive information about the birth process, which helped the fathers to enhance better support to their spouse. When they got sufficient and adequate information they were better able to handle the situation around birth, and they felt safe and secure about their spouse and the unborn baby. If they were given information from the midwives they wanted it to be presented at the proper time and the information should be clear and appropriate. Midwives’ attitudes and engagement were also described. Mostly fathers described midwives as nice and cheery, being responsive and supportive which made the fathers feel welcome and safe. The experience of security resonance well in following statements; ‘‘We had an amazing midwife who helped us and encouraged my wife, and made us feel safe’’, ‘‘But despite the heavy work load they had an encouraging and reassuring manner’’, and ‘‘Undoubtedly one feels helpless, but we had two fantastic midwives with whom we felt safe and secure’’. The quantitative data analysis also pointed out that 62% (n = 138) of the fathers felt safe and secure, this regardless of birth position and mode of birth. Yet, again some experienced the midwives being harsh, nonresponsive and unengaged, demonstrating an ungentle manner. Some of the more lengthy comments were when midwives were described in a negative manner; ‘‘I experienced the latter midwife as little unengaged. She ran on routine and had a practiced style and was not at all as responsive as the first one. I didn’t like her ‘‘harsh’’ approach’’, and ‘‘I felt I was in the way. I took the opportunity to ask when I managed to make eye contact with the midwife only then did I get the information I needed’’. The fathers described in positive sentences their experience of the midwives’ presence in the birthing room in ways such as; ‘‘. . . Luckily, the midwife student was continuously present in the room which was . . . pleasant’’ and ‘‘Good attendance and control on behalf of the midwife’’. On the other hand, when the midwives were spent only a limited time with the couple in the birthing room they said; ‘‘. . . We hardly met her [the midwife], only her student’’, ‘‘They were absent a lot; they were not so much with us’’, and ‘‘I noticed that the
Please cite this article in press as: Johansson M, Thies-Lagergren L. Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.06.001
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staff had much to do. They spent very little time in the room . . . during the first stage of labour’’.
Table 1 The fathers’ birth experiences and emotions in relation to maternal birth position.
x2
Spontaneous vaginal birth
3.2.2. Obstetrical competence of professionals The importance of professionalism was mentioned in the fathers’ portrayals. Expressions like experienced, skilled, competent, quick, and planning were mentioned several times. Some expressed that they received incredibly good help throughout the birth and they felt very comfortable and taken good care of by the skilled staff. The fathers felt that the midwives were in control of the situation, that the midwives knew when and how to act. This competence can be exemplified by ‘‘an experienced midwife who resolutely fashioned a sheet in a way that allowed it to be used in a tugof-war manner, giving my partner good leverage when pushing, which worked excellently in aiding the child’s birth’’. However, some fathers experienced the midwives as less experienced with, for example, a poor planning regarding painrelief; ‘‘No one listened to me and my wife, they did whatever they pleased without asking us, like suturing my wife without anesthesia’’. When the professionals were lacking obstetrical competence the fathers felt they had to be persistent and they felt insecure. 3.2.3. Organisation of midwifery care The fathers spontaneously commented on the organisation regarding midwifery care. The organisation concerning changing of staff during birth resulted in several comments. The fathers were critical to this, expressed feelings of insecurity and they did not have enough time to build a sense of trust towards the midwife who entered the room to assist the birth at the very end. The fathers described this as ‘‘It was really bad luck . . .’’, ‘‘I’m a bit critical of the sudden change of staff. . .’’, and ‘‘. . .the midwife who took over could unfortunately not build any confidence so it was not quite good in a security-sense at this time’’. On the other hand a change of staff could also be experienced as positive and improve the birth experience; ‘‘. . . but the midwife who took over, gave us all the confidence we needed’’. 3.3. The birth process’ impact The second category revealed in the qualitative data analysis was labelled ‘The birth process’ impact’ and involved two subcategories, which were labelled as ‘Overall experience of the birth process’ and ‘An upright birth position was mostly regarded as positive’. 3.3.1. Overall experience of the birth process In total 174 (78.7%) had a positive overall birth experience. The fathers were more likely to have had experienced the birth as an overall positive event, this revealed both in the quantitative and qualitative data analysis. Some examples of positive statements were; ‘‘It’s a very cosy, nice and incredible experience’’, ‘‘. . .Absolutely fantastic’’ and ‘‘A powerful and positive experience’’. Important issues for strain related to the overall birth experience were when the spouse had a horizontal birth position, instrumental birth, prolonged time for the process of labour and birth, labour pain and if complications for the spouse and/or the new-born child arose. Those who had a spouse with an upright birth position during a spontaneous vaginal birth were significantly more likely to have a positive birth experience compared to those having a spouse adopted a horizontal birth position (r = 0.048) (Table 1). The fathers who had a spouse delivered by vacuum extraction were more likely to have a positive birth experience compared to emergency caesarean section (n = 20, 71% vs. n = 1, 11%; r = 0.003). Fathers with a spouse delivered by emergency caesarean section described the event as ‘‘a traumatic experience’’ and ‘‘the most horrible, but still the best experience of my life’’. When their child was born by vacuum extraction some fathers expressed that as a
Upright
a
b
Horizontal
p-Value
n = 91
n = 93
n (%)
n (%)
81 (89.0) 10 (11.0)
72 (77.4) 21 (22.6)
0.048
Emotions free to chose from for the spouse’s birth position Safe and secure (Yes) 60 (65.9) 55 (59.1) Comfortable (Yes) 50 (54.9) 31 (33.3) Relaxed (Yes) 24 (26.4) 16 (16.1) Strong (Yes) 23 (25.3) 15 (16.1) Powerful (Yes) 19 (20.9) 8 (8.6)
0.341 0.003 0.132 0.125 0.019
Overall birth experience Positive Less than positive
Experiences of the spouse’s birth position assessed by Visual Analogue Scalec 0 till 7 20 (22.0) 39 (41.9) 71 (78.0) 54 (58.1) 0.005 8 till 10 a b c
Birth seat, kneeling and standing birth position. Semi-recumbent, supine, lithotomy, left-lateral birth position. Visual Analogue Scale 0 = Very negative, 10 = Very positive.
stressful experience but they were ‘‘grateful for the child coming the natural way’’, and ‘‘that was fine with all the support from all the professionals . . .’’. The quantitative data analysis pointed out that 80% (n = 177) of the fathers were not relaxed during the spouse’s second stage of labour this regardless of mode of birth. However, there were no statistical differences between fathers’ emotion of being relaxed if the spouse had an upright or horizontal birth position during a spontaneous vaginal birth (Table 1). The aspect of time was expressed with great variation. When the birth process was experienced as quick and rapid they regarded it as positive, good and smooth, one father expressed this like; ‘‘The birth was significantly faster and more straightforward than expected, which must be regarded as positive’’. However, one father regarded the rapid pace as negative when it caused limited time for discussions. In the quantitative data analysis it became evident that fathers who experienced their spouse giving birth in an upright position, were more likely to have had experienced the birth being more rapid (mean VAS 6.31 vs. 4.41), and judged the second stage of labour more rapid (mean VAS 7.01 vs. 4.53) compared to women having a horizontal birth position during a spontaneous vaginal birth (Table 2). When the process of birth was regarded as going on well, flowing calmly or at an appropriate pace they experienced the labour process as very smooth. When the process of labour on the contrary was long and slow, feelings of helplessness, anxiousness, confusion, tiredness, feeling less positive and being upset were aroused. One father whose child was born by vacuum extraction expressed; ‘‘It was a difficult birth
Table 2 The fathers’ experiences of length of childbirth in relation to maternal birth position.
Assessed by Visual Analogue Scale (VAS)c for Experience of length of labour and birth Experience of length of second stage of labour a b c
Spontaneous vaginal birth
t-Test
Uprighta
Horizontalb
p-Value
n = 91
n = 93
Mean (sd)
Mean (sd)
6.31 (2.78)
4.41 (3.40)
<0.001
7.01 (2.50)
4.53 (3.37)
<0.001
Birth seat, kneeling and standing birth position. Semi-recumbent, supine, lithotomy, left-lateral birth position. VAS 0 = prolonged, 10 = rapid.
Please cite this article in press as: Johansson M, Thies-Lagergren L. Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.06.001
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because it took a very long time and eventually became critical’’. Another father explained; ‘‘It took longer time than I thought; I felt that the staff was a little worried when it took longer than they thought. They kept telling me that now it’s not far away, then another 3 hours passed. This made me worried for the sake of my girlfriend and child.’’ Labour pain caused the fathers to feel helpless, strained, tense, nervous, and uncomfortable. Comments like; ‘‘It affected me negatively and I could not do anything’’, and ‘‘. . . my wife was in great pain but I couldn’t do anything about it’’ were described by the fathers. One father was feeling powerless despite acknowledging his wife strength and his ability to support his wife. ‘‘It was difficult to see how my wife suffered; I gave her all the support I could, but still felt powerless because I could not take the pain upon me. She was so strong, stronger than ever.’’ In case of complications for the spouse and/or the new-born child it caused strain for the fathers. Some experienced labour dystocia being very stressful, other expressed that severe perineal trauma was laborious. Some expressed fear of death when the spouse lost blood after birth and a frightening situation was also when the new-born child needed resuscitation which illustrates in; ‘‘Some complications arose when the baby came out and it was quite traumatizing. The child’s breathing was not working properly’’. 3.3.2. An upright birth position was mostly regarded as positive Most common maternal birth position during a spontaneous vaginal birth was birth seat (n = 83; 45.1%) (Table 3), and the fathers in this group were more likely to assess the birth position as very positive, i.e. VAS 10 (n = 40; 54.8%) compared to other upright and horizontal birth positions. Most common birth position during a spontaneous vaginal birth with a horizontal birth position was lithotomy (n = 30; 32.2%) (Table 3), approximately one third of these fathers assessed the birth position as very positive, i.e. VAS 10. The fathers with a spouse having a spontaneous vaginal birth were more likely to judge an upright birth position as positive (VAS 8–10) compared to a horizontal birth position (r = 0.005) (Table 1). The aspect of being comfortable was pointed out in the quantitative data analysis as 40.3% (n = 89) of the fathers experiencing being comfortable during the second stage of labour, this regardless of birth mode. The fathers with a spouse having an upright position were more likely to have felt comfortable compared to those whose spouse was in a horizontal birth position during a spontaneous vaginal birth (r = 0.003) (Table 1). This finding was corroborated in the qualitative data analysis as; ‘‘She tested various positions, but the birth seat was the most comfortable. It was also the one that I liked the most’’. On the contrary when not feeling comfortable one father explained; ‘‘The only time that I felt uncomfortable was during the very last part of the second stage of labour then it seemed to hurt incredibly much’’.
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The fathers were also more likely to experience the birth as powerful when the spouse was in an upright birth position during a spontaneous vaginal birth this compared to a horizontal birth position (r = 0.019) (Table 1). The issue of power was described in the quotes as; ‘‘I wonder if we got a little more lacerations since we felt a very satisfying surge of power during the second stage of labour . . ., but as I said, we were contented.’’ Solely fathers who had experienced their spouse giving birth on a birth seat commented on their own experiences regarding birth position during the second stage of labour. The experiences were described as ‘‘the birth seat enhanced birth becoming a fantastic experience’’; ‘‘. . . my wife had not made it without the birth seat’’ and ‘‘. . . the birth seat was very helpful and it became a more natural position to give birth in . . .’’. Several fathers recommended this birth position to other couples. However, a couple of fathers did not find the birth seat being a good option or were disappointed with the birth seat; ‘‘. . . the birth seat did not work as we had hoped it would’’ and ‘‘. . . my wife could not positioning herself in a comfortable way’’. Of the fathers who had a spouse in a birth seat position 20.5% (n = 17) assessed the position as VAS 0–7 (Table 3). This negative experience was described as; ‘‘. . .the midwife was not so used to assist how to sit on [the birth seat]. How I should sit was improvised, and the chair I was sitting on had no cushion. A pillow to have between me and her back was forgotten. Once we sat down my wife could not reach the oxygen mask so we had to move . . . So I felt she [the midwife] was a little bit in-experienced and had not fully track of how to support a birthing woman on a birth seat’’. 3.4. Being prepared to participate The third category was labelled ‘Being prepared to participate’ and involved two subcategories, which emphasised the importance of being prepared for labour and birth, and to participate in the process of birth. The fathers described preparation with breathing and relaxing techniques and reading literature which helped them feel safe and in control. If the preparation was lacking, they felt, on the contrary, lost, pressed and did not know what to expect as well as not knowing what might be more or less helpful. In spite of preparation activities some fathers pointed out labour and birth as something new, hard to imagine in beforehand, nothing one could imagine or being in an unknown territory. One father said he felt unprepared for the birth event and he was the one to blame. Birth preparation with breathing and relaxing techniques and professionals who introduced them to techniques in how to support the spouse during labour made the fathers involved and they experienced that they could contribute with protection and coaching. When they experienced participation they felt it fantastic. Many fathers described feelings of weakness, fear, intensity, apathy, being in an own ‘bubble’, this consequently leading to
Table 3 Fathers’ experience of maternal birth position by Visual Analogue Scale (VAS). Spontaneous vaginal birth Horizontal birth positionb n = 93
Upright birth position n = 91 Birth seat
Kneeling
Standing
Lithotomy
Supine
Semi-recumbent
Left-lateral
n = 83
n=6
n=2
n = 30
n = 29
n = 25
n=9
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
1 (50.0) 1 (50.0)
10 (33.3) 20 (66.7)
10 (34.5) 19 (65.5)
12 (48.0) 13 (52.0)
4 (44.4) 5 (55.6)
Experiences of partner’s birth position by VASa 0–7 17 (20.5) 2 (33.3) 8–10 66 (79.5) 4 (66.7) a b
0 = very negative, 10 = very positive. Horizontal birth position with exclusion for vacuum extraction and caesarean section.
Please cite this article in press as: Johansson M, Thies-Lagergren L. Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.06.001
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difficulties in realizing their role in supporting the spouse. They felt they should have stood up for their partner even more but they did not have any impact over the birth process. One father expressed; ‘‘I was the most unnecessary part of the birth. The feeling I got in the room was that I wanted to go away, but I did not want to miss the moment when my child was born. The fathers should be included in a more inviting way.’’ Some fathers had wanted to be more involved. They felt that the midwives should have been more active involving them in the birth process; that the fathers ought to be involved. One father said that he felt that the midwife did not find that becoming a father was important. However, fathers whose partner gave birth on the birth seat expressed feelings of participation; ‘‘Because my wife had her arms on my legs like arm-rests, I felt involved and I don’t think I should have done so if I had been standing beside her. To really get to know how much power there is behind giving birth to a baby was fantastic . . . Afterwards, I got a feeling that I also had been giving birth.’’ ‘‘As a father, sitting behind my beloved and being able to participate through the entire birth was very important for me.’’ 4. Discussion This study is unique as it, to the best of the authors’ knowledge, probably is the first paper of its kind to describe and explore fathers’ experience of their spouse’s birth position in the second stage of labour. It contributes to the growing body of literature about fathers’ experiences of childbirth. The findings of this study revealed that eight out of ten fathers had a positive overall birth experience. Those with a spouse who had given birth in an upright birth position were more likely to have had a positive overall birth experience, to feel comfortable and powerful compared to those who had a partner who adopted a horizontal birth position. When the spouses had had an upright birth position the fathers experienced a shorter birth compared to spouses having a horizontal birth position. A positive birth experience among fathers was related to midwives ability to be professional and to be prepared for participation in labour and birth. 4.1. The impact of an upright birth position In most cultures, birthing in a bed is regarded as customary and expected by both parents-to-be and for birth attendees.7 The preferences for birth positions and the philosophies of professionals have an impact upon positions that women adopt during birth.9 The fathers in this study had a more overall positive birth experience when the spouse had an upright position in the second stage of labour compared to fathers who had an experience of a horizontal position. This is concurrent with the only study identified describing fathers’ experience regarding birth position.18 The advice of birthing position given by midwives during the second stage of labour has influenced the women’s preference of birthing positions. Other sources that influence the positions are midwives’ information during antenatal classes and other women’s stories.6 Freedom to change positions in labour has been identified as integral to a feeling of control and the management of pain in labour, due to the physical and psychological benefits. To feel in control has been experienced when women are able to choose the most comfortable birth position.9,19 Issues related to women’s sense of control during the second stage of labour have been influenced on adopted birth position (self or self together with others) and labour pain. The negative effect of labour pain was less in multiparous women than in primiparous women.20 Women
have described being in more control over their pushing in the second stage when they were in an upright position compared to a supine position.6 In this study the birth seat position gave the fathers feelings of being comfortable and powerful. The fathers were more likely to experience the birth as more rapid when the woman adopted an upright birth position. When the birth process was experienced as quick, smooth and rapid they regarded it as positive. Advantages of an upright position include shorter second stage of labour.7,9,10,12 Any upright or lateral birth positions compared with supine or lithotomy positions have been associated with reduced duration of second stage of labour.10 A fast progress of labour has given multiparous women an increased feeling of control,19 and in this study the fathers regarded a rapid labour process as positive and good. 4.2. Midwives ability to be professional The fathers emphasised in this study the importance of midwives’ attentiveness through interaction and communicating skills for their birth experience. To receive information about the birth process was vital. When given sufficient and adequate information they were better able to handle the situation, and they felt safe and secure. The quality of midwives communication and interaction with expectant fathers had a big impact upon men’s level of engagement and their active involvement in the process of birth. Respectful behaviour and language on the part of the professionals have had an impact on fathers’ sense of involvement. Fathers working in partnership with the midwife have been described as a factor leading to better being able to support the woman. The fathers then felt that they were being of use to their woman.5 In a Swedish interview study it became evident that the team of professionals in case of a caesarean section played a key role for fathers’ birth experience. Important aspects of a positive experience were the professionals’ ability to share information, as well as their attitudes and behaviour. The fathers valued when the staff spoke with them, explained and kept them ‘up to date’.21 Lack of designated information for expectant fathers during labour and birth has furthermore been related to feelings of distress and a less positive birth experience.5,22 The importance of professional obstetrical competence was also mentioned in the fathers’ portrayals. A less positive birth experience on the part of fathers has previously been related to questions as to whether the woman was receiving the best possible medical care, if the extent of the midwife’s presence in the birthing room was as desired, with the midwife giving the support needed. On the other hand, when fathers had perceived that the professionals were making adequate decisions during labour and birth, feelings of a wonderful and fantastic experience ensured, leading to satisfaction with care provided.22 4.3. Being prepared to participate Feeling prepared for labour and birth gave the fathers a sense of safety and control in the unknown process of childbirth explored by this study. Fathers often want to participate and to be involved in the care of their female partner during labour and birth. This involvement also has a positive impact on their experience of the birth of their child.5,22 Fathers have previously recognised birth as a unique event that may be potentially challenging requiring a level of preparation. For first time fathers childbirth has been regarded as an unknown territory. Because of that, men’s mental and physical preparation was important for their ability to be actively involved in the labour and birth of their child. When a feeling of being prepared was lacking the fathers were more likely to feel out of control and could not support the woman in the birth
Please cite this article in press as: Johansson M, Thies-Lagergren L. Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.06.001
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process.5 In this study fathers having a spouse who had a birth seat position expressed feelings of participation through this birth position. In a Dutch qualitative study it was reported that from a maternal point of view the father rarely influenced the choice of position and their support for a specific position was not an important factor.6 But, if the birthing woman has an influence on the birthing position together with others, such as the midwife or the expectant father then this has been related to a higher sense of control than when having such an influence only by themselves.20 In an RCT from Sweden regarding birth position in the second stage of labour, it was reported that expectant fathers in the experimental group (birth seat) felt more supportive, more involved and more satisfied with their own contribution during the second stage of labour than expectant fathers in the control group (supine position).18 Being in an upright position in the second stage of labour makes both fathers and birthing women feel more involved in the birth process.23 It can be assumed that fathers experiencing birth in an upright position will make them feel more authentically engaged and supportive. In order to facilitate a positive birth experience for fathers, midwives must include them in conversations and in the support and care for the woman.24 Fathers often feel that they are able to support their labouring spouse to some extent. They could give back massage,6,25 more easily when the women adopt a birthing stool position.6 It was also easier to help her change her position during labour.25 The support person is also known to frequently imitate the professional caregiver’s instructions during the second stage of labour.26 Women’s perception of feeling supported during labour can alter the perception of pain, allowing women to respond instinctively in labour, and lead to ultimate feelings of satisfaction with the birthing process. Women require unrestricted access to their choice of support people, continuous emotional and physical support from a skilled woman and continuous midwifery care, which is seen to result in increased satisfaction.9 4.4. Methodological considerations and limitations Several limitations should be discussed. Initially 1002 male partners to the included participants of women in the original RCT,12 were invited to this follow up-study. Approximately 22% responded, a relatively low response rate, which must be taken into consideration when interpreting the findings, and generalizability of the study may be limited. The collection of data was, for some respondents, delayed for as long as four years as became apparent once the analysis of the original RCT was complete, thus it became necessary to carry out a follow-up study. This relatively long time-span between birth of their child and receiving the questionnaire may also have caused the low response rate. Previous research has suggested that women’s memories of childbirth are generally accurate, even years later,27 which probably apply for fathers as well. No literature regarding fathers’ long-time perception or memory of childbirth has been identified, however it has been suggested that individual’s memories of birth experiences are accurate and will remain consistent over a long period of time when being personally involved.28 Furthermore, fathers were not questioned on the subject of having any previous children which is a limitation within this study. However, only nulliparous women were included in the original RCT, and therefore the fathers perhaps were more likely to be first time fathers. The fathers were asked to write down their overall experience of the birth in their own words; they were not specifically asked to express their experiences of maternal birth position during the second stage of labour. This probably resulted in lack of information regarding their explicit experience of the actual birth position. However, the fathers who had experienced the birth seat were the only ones who specifically commented on the birth
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position and it can therefore be assumed that this birth position had an impact on the overall birth experience. This assumption is in line also with results reported by Waldenstro¨m and Gottvall.18 The abstraction in the content analysis was restricted by the limited content of the comments. The use of the mixed-method approach applied in this study may prove additional strength as the qualitative data helped validate the quantitative ones, to amplify and give a more personal insight into the fathers’ experience of the birth position their spouse adopted in the second stage of labour.14 4.5. Conclusion This mixed-method study contributes with more data on what makes the birth experience positive for expecting fathers. The study revealed that an upright position in the second stage of labour, in particular when a birth seat is facilitated, enhances fathers’ feelings of being actively engaged in the birth process. In addition the upright position made the fathers feel comfortable and powerful. Midwives can enhance fathers’ feelings of involvement and participation by attentiveness through interaction and communicating skills. Acknowledgements and disclosures This study was supported by grants from the Stig and Ragna Gorthon Foundation, Selma Zoega’s Foundation and professor emeritus Vivian Wahlberg’s fund which we gratefully acknowledge. Our thanks also go to all fathers who willingly responded to the on-line questionnaire reported in this article, and to Sara Ingero¨ who gave helpful advice on the language editing. The authors have no disclosures to report. References 1. Green J, Amis D, Hotelling BA. Care practice #3: continuous labor support. J Perinat Educ 2007;16(3):25–8. 2. Plantin A, Olukoya AA, Ny P. Positive health outcomes of fathers’ involvement in pregnancy and childbirth. Paternal support: a scope study literature review. Fathering 2011;9(1):87–102. 3. Lavender T, Walkinshaw SA, Walton I. A prospective study of women’s views of factors contributing to a positive birth experience. Midwifery 1999;15(1):40–6. 4. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2013;15(7):CD003766. [Epub ahead of print]. 5. Johansson M, Fenwick J, Premberg A˚.. A meta-synthesis of fathers’ experiences of their partner’s labour and the birth of their baby. Midwifery 2015;31(1):9–18. 6. De Jonge A, Lagro-Janssen AL. Birthing positions. A qualitative study into the views of women about various birthing positions. J Psychosom Obstet Gynaecol 2004;25(1):47–55. 7. Roberts JE. The ‘‘push’’ for evidence: management of the second stage. J Midwifery Womens Health 2002;47(1):2–15. 8. Thies-Lagergren L. The Swedish birth seat trial (thesis). Stockholm; 2013. Available at: http://www.helsingborgslasarett.se/download/18.1859dfd713 ef5dbab6b193/1370003381188/Thies-Lagergren+Li.pdf [accessed 11.04.15]. 9. Priddis H, Dahlen H, Schmied V. What are the facilitators, inhibitors, and implications of birth positioning? A review of the literature. Women Birth 2012;25(3):100–6. 10. Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev 2012;16(5.). Art. No.: CD002006 [accessed 11.04.15]. 11. Thies-Lagergren L, Kvist LJ, Christensson K, Hildingsson I. Striving for scientific stringency: a re-analysis of a randomised controlled trial considering first-time mothers’ obstetric outcomes in relation to birth position. BMC Pregnancy Childbirth 2012;12:135. 12. Thies-Lagergren L, Kvist LJ, Christensson K, Hildingsson I. No reduction in instrumental vaginal births and no increased risk for adverse perineal outcome in nulliparous women giving birth on a birth seat: results of a Swedish randomized controlled trial. BMC Pregnancy Childbirth 2011;11:22. 13. Erlandsson K, Lindgren H. From belonging to belonging through a blessed moment of love for a child – the birth of a child from the fathers’ perspective. J Mens Health 2009;6(4):338–44. ¨ stlund U, Kidd L, Wengstro¨m Y, Rowa-Dewar N. Combining qualitative and 14. O quantitative research within mixed method research designs: a methodological review. Int J Nurs Stud 2011;48(3):369–83.
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Please cite this article in press as: Johansson M, Thies-Lagergren L. Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.06.001