Background
Methods
Design
Presuppositions and preunderstandings of researchers
The concept of patient-centered care
Respecting patients’ values, preferences, and needs Subjective quality of life, needs, autonomy, and sense of well-being | Physical comfort Pain management, activities, and hospital environment |
Coordination and integration of clinical care Clear delegation of responsibility, effective communication between health team members, and administrative and organizational support | Information, communication, and education Giving women knowledge about and clear understanding of status, progress, prognosis, processes of care, and self-care options |
Transition and continuity Understanding of planning of care, supporting resources, and relevant information at discharge | Emotional support and alleviation of fear and anxiety Relief of anxiety regarding care and treatment and impact on self and family |
Involvement of family and friends Support, accommodation, encouragement, and recognition of role and needs of family |
Setting
Alternative delivery room | Danish standard delivery room | |
---|---|---|
Guiding focus of the physical birth environment | Promoting feelings of well-being, freedom, and control. A safe and normal birth with minimal intervention | Medical safety |
Visual and auditory stimuli | Snoezelen-inspired audial and visual scenery on three walls providing positive distractions | The woman may bring own sound device |
Interior, furniture, and equipment | Nordic contemporary style furniture resembling private home environment | Traditional hospital furniture and equipment, including lounge chair |
Traditional hospital labor bed and necessary equipment covered or placed less visibly | Traditional hospital labor bed as central feature of room | |
Bathtub | Bathtub may be available | |
Relaxation area with sofa bed, chairs, and coffee table | ||
Privacy | Single occupancy, private bathroom | Single occupancy, often private bathroom |
Light | Overhead light off unless needed for assessment purposes | Overhead light controlled by staff, usually on unless the woman is sleeping |
Dimly lit scenario projections controlled by woman and her partner | ||
Dimmed light in relaxation area |
Participants and recruitment
Woman | Age | Highest degree or educational level achieved | Marital status | Birth complications |
---|---|---|---|---|
1 | 27 | Bachelor | Married | |
2 | 24 | Bachelor | Cohabiting | Yes |
3 | 25 | Bachelor | Cohabiting | |
4 | 26 | Bachelor | Cohabiting | |
5 | 31 | Master | Cohabiting | Yes |
6 | 29 | Upper secondary | Cohabiting | Yes |
7 | 29 | Master | Cohabiting | Yes |
8 | 26 | Bachelor | Married | Yes |
9 | 25 | Bachelor | Cohabiting | |
10 | 28 | Bachelor | Married | |
11 | 25 | Master | Cohabiting | |
12 | 28 | Upper secondary | Cohabiting | Yes |
13 | 29 | Bachelor | Married | Yes |
14 | 28 | Bachelor | Cohabiting | Yes |
Data collection
Data analyses
Results
Analysis
Themes | Sub-themes |
---|---|
Emotional support | Feeling welcome |
Midwife and room inseparability | |
Involvement of partner | Feeling equal |
A space for the partner | |
Physical comfort | Positive distractions |
Capturing the room |
Themes
Emotional support
When describing such feelings, the women made associations to a recognizable home-like environment. “Feeling welcome” appeared to be closely associated with the women’s experience of emotional support, comfort and the reduction of the stress and uncertainty experienced in connection with admission for birth. None of the women in our study expressed experiences of stressful elements or limitations induced by spoken and unspoken rules governing the room. The physical environment seemed to support the women’s experience of being a vital part of the organization they now entered, which is especially important if a patient-centered approach is to be supported [24]. Moreover, it seemed to make the women adapt easily to the room and to the transition from home to hospital.… I kind of felt ... love behind it. Yes, I thought, okay ... do they really put so much effort in for us coming here? It gave me a great feeling of being embraced … (Informant 10).
The women gave examples of how the room and its audial and visual stimuli created opportunities for small talk and how they perceived this as calming. However, all the women in the study also expressed a need for guidance from the midwife, as they found themselves in unknown territory and overwhelmed by pain. One of the women spoke for many when describing her experience of such guidance:…Well, she wasn’t just sitting there writing, or only present when it was to do with the birth ... she could also talk about other things – that was super nice. Because it also makes her a little more human. It was simply amazing. There's nothing better than when people share a little bit of themselves. Because … it somehow calms you down – it really does … (Informant 12)
Our data indicate that in general the midwifes working in the alternative delivery room were successful in helping the women “surrender” themselves to the birth process and guide them into a sense of physical and psychological control. However, the amply spaced room and the physical facilities also facilitated another form of emotional support, as it allowed the midwife to retreat and offer a private space for the couple while remaining available to them. The women valued this occasional “professional retreat” for the opportunity it gave them to find strength through close connectedness with their partner while maintaining a feeling of safety and being cared for. The following quote is typical:… and I really needed that (…) I remember staring intensely into her eyes. She was so good at keeping my gaze and helping with breathing and everything. I was like … you know, I just surrendered myself … (Informant 14)
The possibility for midwives to change between closeness and respectful distance seemed to increase the women’s confidence in their own abilities and sense of control. One woman explained this as:Really, the good thing was ... that she was there – and that she was there almost without us seeing her. Because she was sitting, like in a corner. (…) We could talk about all sorts of things (…) things she didn’t have to know. I think it was (…) we were really just – completely ourselves. And that was really the reason we felt as great as we did. (Informant 12)
The opportunity to create privacy in an unobtrusive way provides a key example of how the room enabled the midwives to adapt to different situations. Moreover, the environment seemed, in the majority of cases, to support or preserve the midwives ‘ability to provide a sensitivity to individual variations which is essential in ensuring patients’ experience of emotional support [24]. However, for few women the overall birth experience was overshadowed by their experience of insufficient emotional support from the midwives. They reported poor communication and misinterpretation of their needs, which led to anxiety and feelings of powerlessness. For instance, one woman described her frustration as:I think she felt that I also could manage on my own … well I actually think it was such a good combination...She made it seem so natural so that we could feel we were the ones in charge…so we could feel comfortable.. yes well, it made me feel safe that I knew she was there anyway and that she was calm... it made me less stressful. (Informant 6)
This seemed to emphasize what is known in a patient centered approach, that if patients’ emotional needs are not met, their usual resilience and ability to cope with stressful situation can be compromised [24]. The birth environment thus seems to be subordinate to the woman–caregiver relationship in the women’s assessment of their birth experiences.I thought aren’t anyone going to help me? Is it not a Midwife’s job to say; Well then you take your breast and… There was NOTHING. I felt like the worst mother ever on earth ... I did not know how I was going to get her to breastfeed... and then I got afraid and you know... she was completely naked and s smooth. I felt so stupid…It ruined the whole experience of the birth for me. (Informant 4)
Involvement of partner
Our data clearly indicate that the sofa bed was the key feature and a major asset of the room. Most of the women talked excitedly about its role in their overall experience, even though it varied whether they had used it before or after birth (no participant used it for the birth although this was also possible). The sofa bed facilitated physical contact between the woman and her partner and strengthened her experience of intimacy and closeness with the partner, which the women saw as stimulating for their sense of partnership. A typical comment was:... we were in there together, you know. It wasn’t all just about me … it was more like it was about both of us. When you’re sitting together, and I’m sitting the same way as him … not just lying in that damn bed. It makes a world of difference getting out of that bed. Because once you’re in it, you are a patient. And I didn’t feel like a patient when I walked around with him … or sat in that cushion area with him. You’re in it together. (Informant 8)
Maintaining intimacy and being equal was key to the women’s general experience of a high level of psychosocial support from their partner. In interpretation of our data, it seems that the women and her partner, in their way of being together in the room, must have experienced the physical environment to signal, encourage and allowing the partner, in some degree, to be involved in the care for the woman during childbirth. This is considered an essential aspect of patient-centered care which supports a family-centered approach [24] and clearly of great meaning to the women.… he was sitting right by my side on the sofa. I could feel his presence. He was … I could feel his legs ... it gave me a sense of security and tranquility. You know, we’re together in this, even if I’m doing the hard work. Anyway, having him alongside me, feeling him... was great for me. (Informant 13)
The sofa area afforded the partner an occasional retreat and the couple a chance to relax individually and in different ways without being separated. The women thus felt that the partner was always present when needed. The women seemed to experience that the sofa bed was an explicit sign that the environment acknowledged partner’s needs, which also were experienced supportive to the women’s needs.The corner made all the difference ... for the father too, and I actually felt that it was great for me as well. Because I felt like “Now I don’t have to worry about him”. I thought it was really nice ... because it means something. The person you’ve got with you in the room, you know, it’s someone you are extremely fond of … (Informant 12)
Physical comfort
Many of the women were able to recall their state of mind and body during labor, and they associated it with relaxation and joy. The stimuli elicited positive emotions in the birth environment, as they associated to important aspects of the couples’ daily lives. For instance, one woman said:It was just really nice for me, you know – the peace in just watching that [the projected images]. Somehow, I'm just inside this bubble. It was ... I really felt like I was in a bubble. It really helped me keep myself going, you know, maintaining the relaxed state I wanted to achieve … and it also turned out to be really good for me. (Informant 8)
Many other distractions, such as childhood memories from the beach, were described by the women and their partners. Although they did not all enjoy such reminders of important aspects of their daily lives, they were all positive about the social interaction that the landscapes and sounds had given rise to.… [the landscape images] made him recall his experiences hunting (…) He kind of liked watching it. So we talked a lot about that – also with the midwife ... it was really nice… (Informant 10)
In general, the warm, dimmed light in the room contributed to the women’s sense of comfort and being in a safe environment. Overall, they used and perceived the light and the distractions very differently. While some of the women did not register the audial and visual distractions during labor, they still emphasized the overall positive contribution of these stimuli in creating an positive ambience. A few women found that the audial and visual distraction compromised their ability to relax. However, as the women and their partners were given control of the sound, light, and the projected landscapes according to their current needs, stressful situations were avoided. Regardless of initiative tacking in the physical environment to support physical comfort, safeguarding of the woman and her partner’s autonomy is therefore a significant environmental factor in the support a patient centered approach.The light was so calming, I think. Like, there was no stress … you know, it was kind of more relaxing – a good feeling, with nothing to feel bad about, you know. We weren’t waiting, or afraid that something bad might happen, the way you might be in a hospital. (Informant 6)
The tranquility and physical comfort provided by the room seemed to stimulate the women and their partners to move around freely to explore different spaces for relaxation and pain relief without feeling a need to ask the staff for permission or help. While many of the women found well-being in the bathtub, by walking around and adapting different positions close to their partner on the sofa bed, some also found the traditional hospital bed helpful. The environment seemed to support the recommendation in a patient centered approach to explicitly address and expand patients’ opportunity for individual-controlled options for pain relief [24]. However, all women gave birth in the traditional hospital bed, even though many expressed that they would rather have been giving birth in the bathtub or on the sofa bed. Many factors may be causing this, however as the women did not know the reason behind the decision to give birth in the traditional hospital bed, this could suggest that exploration of possibilities for alternative birth positions and communication regarding this depends on the guiding of the midwife.I kind of felt I had to try capture the room in some way. Instead of just sitting and watching ... all of a sudden, I found it quite exciting and it made me feel comfortable … (Informant 8)