Labour onset and early labour. An exploration of first-time mothers’ and midwives’ experiences

This dissertation is about how women experience waiting for the onset of labour, and how first-time mothers and midwives communicate during the early phases of labour. Most women in Norway give birth in public hospitals, which is the context used for this study, with the experiences explored within a scientific tradition of lifeworld research. Seventeen women and 18 midwives participated in the study. The empirical material stems from diaries, observations of admissions and in-depth interviews with the women, in addition to focus group discussions with the midwives. The women were recruited while attending childbirth education classes either in the hospital or in a public health clinic. The inclusion criteria were that they were expecting their first child, had a healthy pregnancy with no pathological conditions and were able to communicate in Norwegian. The midwives who participated in the project were currently practicing in either one or the other of two delivery units in the hospital. The dissertation includes three papers that address three different research questions. Paper I explores first-time mothers’ experiences of the contact with the labour ward before hospitalization, and mainly draws on the in-depth interviews carried out in the weeks after giving birth. The observation of three women’s admissions yielded additionally valuable information to the analysis of the material. One of the central discoveries made in this paper is that the women had to negotiate their credibility in order to obtain access to the labour ward. They negotiated with the midwives through the requisite pattern of regularity, although the demanded pattern did not always match their experiences. This paper reveals the women’s vulnerability in their attempts to avoid being sent home from the hospital because it was “too soon” to be admitted. Paper II explores first-time mothers’ experiences of waiting for the onset of labour. This paper draws on the diaries written by the women during the last days of their pregnancy, as well as the retrospective reflections on the experience of waiting given in the interviews. The paper shows that the estimated date of delivery, which was calculated with the help of ultrasound scanning, played a pivotal role in shaping the women’s experiences. The participants entered a state of active waiting, the so-called “waiting mode”, in the days around the estimated due date. Before the study participants got to the waiting mode, they hesitated to relate bodily changes to labour, and rarely interpreted new bodily signs as indications of labour onset. When the pregnant women entered the “waiting mode”, there was a marked change in the way the interpreted their bodily sensations. The women experienced being in a state of constant bodily alertness, their bodies felt all-consuming and they experienced themselves as being “more and more body”. Paper III explores midwives’ priorities and strategies in communicating with first-time mothers in early labour by phone and during check-ups. The material includes three focus group discussions with both experienced and less experienced midwives working in the labour ward. The paper indicates that the midwives’ overall strategy was to encourage women to remain out of the hospital for as long as possible “for their own good”, in order to “protect” the women from unnecessary interventions and complications. All three papers contribute to a discussion on the various aspects of contemporary childbirth paradigms and knowledge traditions surrounding childbirth, and how these understandings may shape and influence the women’s experiences and midwives’ practices. The thesis argues that the researched context of women’s experiences and encounters between birthing women and midwives in hospital-based practice is a field that seems to create paradoxes and dilemmas with no apparent solutions. The dissertation does not yield clear indications of the best way to arrange for the care of women in early labour, but hints at the complexity of the research area and at acquiring a broader understanding of how first-time mothers and midwives on the labour ward communicate. Somehow, the communication between the two parties seemed to be “mismatched” in the way that neither of them “achieved the goal”. Many labouring women wanted to come in, whereas many midwives wanted them to stay home. Paradoxically, both reasons for this action seemed to be embedded in a biomedical paradigm; the women wished to go to a safe place where the medical system could take care of their labours, while the same system produces the likelihood of interventions and complications that the midwives wanted to “protect” the women from. The findings of this study call for reflections and extensive discussions within the midwifery profession in hospital-based contexts. It seemed as if the midwives tacitly accepted the “execution” of the task of being the gatekeepers of the labour ward, without seriously exploring the underpinnings of their professional decisions. It appears to be a bit strange that they persuaded women to stay home for as long as possible, rather than questioning their own professional role in trying to reduce the high intervention rate for women admitted in early labour. The dissertation may have implications for how antenatal care is organized and how women are prepared for labour. Pregnancy is managed and surveyed by “the experts”, and women seem to internalize this type of knowledge as being the authoritative knowledge. There is no indication that women do not want to maintain the medical services, but the question is whether it is possible to support women in other ways in order for them to be better prepared for labour and its onset