Provider views
Key themes that emerged from the qualitative data analysis included: the perceived benefits and problems with allowing women to be mobile and deliver in positions other than supine; safety issues; and provider feelings about the skills and confidence required to implement these procedures. Each theme is explored in detail below.
Mobility during labour
Views expressed by midwives and doctors about mobility during labour were generally positive. During focus group discussions, midwives acknowledged the benefits of mobility; the following extracts highlight typical comments:
"It is important and beneficial if the mother moves around during the first stage of labour. This will enhance labour contractions as well as foetal descent." (Midwife, Focus Group Discussion (FGD), referral hospital)
"For me I think mobility during the first stage of labour is important because it helps in descent and it enhances the progress of labour." (Midwife, FGD, coastal district hospital)
During in-depth interviews, doctors also commented on the benefits of mobility in hastening labour and speeding descent:
"Encouraging mobility during labour is good practice because it makes the contractions stronger. If contractions are stronger, the duration of labour will be shorter and there will be fewer interventions, which may be costly and may consume time while the maternal and foetal outcomes are being compromised." (Doctor, interview, district hospital)
"Being mobile helps because when you compare a woman who just stays in bed and that one who moves around, the speed of the engagement of the head will differ although some may say the process of labour takes a natural course. But things like movement and emptying the bladder frequently help in the progress of labour." (Doctor, interview, regional hospital)
One doctor mentioned that mobility reduces pain and anxiety in women during labour:
"Moving around helps the mother psychologically. If a woman stays in bed or in one place, she may feel more pain, but if she walks or moves, this helps in decreasing anxiety and reducing the labour pain." (Doctor, interview, regional hospital).
Both midwives and doctors emphasised that a woman's condition dictated whether or not she could be mobile during labour. They expressed concern that a thorough assessment should take place before a woman is allowed to move around, and those in active or second stage of labour should not be mobile:
"Being mobile or walking around is OK, but it depends on the stage of labour. If a woman is in the first stage of labour and membranes are intact, the woman can be allowed to walk around." (Midwife, FGD, coastal district)
" Walking around is good but with proper assessment and monitoring. If there is no problem with the labour, the woman should be allowed to walk." (Doctor, interview, district hospital)
Provider views about the barriers to allowing women to be mobile during labour typically centred on safety issues and the labour ward environment. A common concern among midwives was that they cannot observe women if they are outside the labour ward; one midwife explained:
"I would feel safe if she walks within the labour ward, not outside. If she goes outside we will lose control. We can not observe her when she is outside." (Midwife, FGD, district hospital)
Other providers feared that they could be blamed for causing danger to the woman and the baby if something happens to the woman outside of the labour ward; a typical comment was:
"Sometimes you may have assessed a woman and found that she is 4 cm dilated. Labour can go fast and if you allow her to walk she may deliver in the toilet or corridor. The midwife will be responsible for the problem." (Midwife, FGD, referral hospital)
Both midwives and doctors mentioned the labour ward environment as a specific barrier to allowing women to be mobile, and they commented on the overcrowding of labour wards, which precludes women from walking around, as one midwife explained:
"It is difficult to encourage women to be mobile because there is overcrowding, too many patients. In the room for women with normal labour there are sometimes 20 patients to one midwife." (Midwife, FGD, Referral)
A doctor even likened the situation in labour ward to that of being in jail:
"To say the truth when women come to our labour ward it is like being in jail. There is no secret about it. Probably the factors that contribute to this – I am not so sure, but if you take a look at the room for normal labour, there are eight beds but there is no space between the beds. I have tried several times to get women out of bed but it is just impossible. The room is overcrowded, completely overcrowded." (Doctor, interview, referral hospital)
In comparison with hospital delivery environment, TBAs delivering women at home or in the community usually encourage their clients to walk around during labour. One TBA explained her normal practice during interview:
"If women are in the initial stage of labour, I ask them if they want to walk, if they say yes, I tell the women to walk but I walk with them, I walked myself while in labour." (TBA, interview, district hospital)
Position for delivery
Qualitative findings revealed provider views about the position adopted for delivery. Both midwives and doctors at all study sites agreed that supine position was used routinely, or was the most common position used:
"At our place it is not usual to deliver women in other positions. It is mainly supine position that we use." (Midwife, FGD, district hospital)
"Supine is the most common delivery position used in our hospitals. We are used to this position. That is the position we were taught and even most of the pictures that are found in midwifery and obstetric books are showing women on their backs with knees flexed as they deliver their babies." (Doctor, interview, regional hospital)
A few midwives mentioned that women are sometimes supported in a more upright position using a pillow, or they are told to flex and hold their legs, but this is not usual practice:
"If a woman insists that she wants to deliver in an upright position and she gives me a genuine reason such as difficulties in breathing or high blood pressure, I can provide her with extra pillows to keep her upright and deliver her in that position, although I am not used to it and personally do not prefer it." (Midwife, FDG, regional hospital)
"I can allow a woman to deliver in upright or lateral position if she is calm. In fact I will be more comfortable to deliver the woman in a lateral position by standing or kneeling behind her and supporting the baby as he comes out." (Midwife, FGD, referral hospital)
In addition, both midwives and doctors were of the opinion that supine position is the most convenient, since it enables the attendant to see clearly what is happening during delivery; a typical comment was:
"Delivering a woman in supine is convenient because the provider can control all activities easily and she or he has good view of the whole process of birth and can easily perform procedures, for example, episiotomy." (Midwife, FGD, coastal district hospital)
A midwife at the district hospital, and one doctor at the coastal district hospital suggested that supine position facilitates communication between the attendant and the woman:
"Supine position allows the provider to see the woman's facial expression. In other positions it might not be easy to observe this and the health care provider may miss non-verbal expressions that can aid in understanding the condition of the mother and how she is responding to the labour process." (Midwife, FGD, district hospital)
"In supine position, the provider and the woman are face to face. You see what you are doing and the mother sees you. You can communicate easily with the mother." (Doctor, interview, coastal district hospital)
Providers proposed various barriers to using upright positions such as sitting, squatting or standing; most comments centred on safety of the woman and provider and lack of experience using positions other than supine. For example, one midwife commented that:
"Sometimes upright position can bring more problems. Because if the woman is in that position (upright) and at that very moment she experiences eclampsia! Now I do not know what you (the care provider) will do? Two things are happening at the same time. Will you help the mother or the baby?" (Midwife, FGD, district coastal hospital)
Doctors also expressed concern about the safety of other positions, one suggested:
"Upright is natural, considering the facts about force of gravity and even how the birth canal is made. It is expected that if a woman delivers in upright position the process will take shorter than in supine position. But upright might not be safe. In the upright position, the mother may drop the baby on the floor, leading to problems." (Doctor, interview, referral hospital)
Regarding provider experience with other positions, most commented that they had been taught to use supine position and did not feel comfortable using other positions:
"Providers are used to supine position, we are taught that way, therefore it is difficult for us to change without being exposed to the procedures of conducting a delivery in non supine positions." (Doctor, interview, coastal district hospital)
"Although the woman has the right to choose the position she likes for delivery, midwives are not conversant with other positions apart from the supine. We were not trained to use these non-supine positions." (Midwife, FGD, referral hospital)
Do providers know what women want?
We asked what providers thought were women's preferences regarding mobility and different positions for delivery. For mobility, we found some inconsistency between what providers thought women wanted and what women said they would prefer. Most doctors we interviewed, and midwives who participated in focus group discussions, suggested women do not like to walk around during labour, but prefer to rest or lie down:
"Many do not like to walk. For those we have there, the most they can do is to go to the toilet. Walking around! No they don't like that." (Doctor, interview, regional hospital)
"Some primigravidas may agree to be mobile when you tell them but mutigravidas may be resistant." (Midwife, FGD, district hospital)
These findings are incompatible with women's preferences identified during exit interviews, which suggested some women do want to be mobile during labour. Of the 671 women who stayed in bed in the labour ward, 28.3% wanted to move around while in labour. More than 37% of women at the district hospital wanted to be mobile; more than 25% of women at the referral and regional hospitals, and 21% at coastal district hospital said they wanted to move around during labour (see table
4).
Provider views and women's preferences regarding position for delivery were mostly consistent. The consensus among midwives was that women are used to supine position, they prefer to lie on their backs, and even turn onto their backs out of habit. The following extracts illustrate typical comments from focus group discussions:
"They (women) like it and are used to supine position. They immediately lie on their backs as soon as a contraction starts, thinking that they are ready to give birth." (Midwife, FGD, coastal district hospital)
"I think women like to lie on their backs. What I have observed is that even if you do not tell them anything about position, they turn and lie on their back." (Midwife, FDG, coastal district hospital)
The doctors we interviewed also agreed that women generally prefer to deliver lying on their back in supine position:
"Women like to lie on their back since generation after generation no other position has been used." (Doctor, interview, regional hospital)
"Women obviously like supine positions since it is used more often. This is the only position they know that is used in health facilities." (Doctor, coastal district hospital)
One doctor described in more detail why this was the case, explaining that women do not have the choice of which position to deliver in:
"A few may not like it (supine position), but they have no choice. Some want to deliver lying on their side or even in upright positions but we tell them to lie on their back." (Doctor, interview, referral hospital)
Provider views were generally comparable to women's preferences identified during exit interviews. As shown in Table
5, the majority of women said they would choose supine position, with very few indicating that they would choose sitting or squatting.
What is required to encourage informed choice for women?
We asked providers what should be done to ensure more informed choices for women for position during labour and delivery in their hospitals. Both midwives and doctors suggested that women should be encouraged to be mobile, since they are currently unaware of the benefits; typical comments included:
"We really cannot say for sure if women do not like being mobile. Women have not been asked. I am sure if we told them of the benefits and asked them their preferences, their responses would be different." (Midwife, FGD, referral hospital)
"If women get the education and are encouraged, and if something is done about the space in the labour wards, women can move around. This education needs to start during antenatal care and also the people at home should know the importance of mobility. Some women are literally carried by their relatives when coming to hospital, even if labour has not progressed." (Midwife, FGD, referral hospital)
Doctors we interviewed specifically mentioned the need for health workers to encourage women to be mobile:
"Women are not encouraged to walk. Health workers tend to forget to educate women on the benefits of mobility." (Doctor, interview, referral hospital)
"I think women need to be encouraged to be mobile since some of them stay immobile due to the belief that they are supposed to stay in bed when they are in the labour ward." (Doctor, interview, regional hospital)
Both midwives and doctors suggested that they required training on the use of positions other than supine and that this would help them to offer more choice to women for their position during labour and delivery:
"Health care providers, especially midwives and doctors need to be trained. The health care providers can then educate and sensitise women on the use of positions other than supine." (Doctor, interview, coastal district hospital)
"We (midwives) need training on other positions. You must know how to deliver the baby if a woman chooses another position like upright or lateral. This training should take into consideration the actual situation in our labour and delivery wards." (Midwife, FGD, referral hospital)