Background
Childbirth is both a social and cultural phenomenon with political implications. It has changed dramatically in the twentieth century, both in developed and developing countries [
1‐
4]. Since the 1980s, increases in the rates of medical interventions at birth, such as the use of epidural analgesia, and cesarean sections, have also raised concerns not only among feminist activists with regards to women's right to have a 'natural' or 'normal' birth, but also in the Society of Obstetricians and Gynecologists of Canada [
1,
5‐
7].
In 2008-2009, the total caesarean section rates in Canada were 26.3% [
8]. Moreover, about two-thirds (69.0%) of all vaginal deliveries in Quebec, and 60% in Ontario, were preceded by epidural analgesia. Electronic Fetal Monitoring (EFM), which was originally designed for high-risk pregnancy, is used in up to 90% of laboring women in recent years in Canada [
9,
10], despite the lack of evidence of its benefits. The total induction rate in Canada ranged from 20.7 to 23.7 per 100 hospital deliveries [
11]. In North America, preterm birth rates increased from 6% in the early 1980s to 8% in more recent years, at least part of the increase is the result of iatrogenecity [
11,
12].
Noticeably, women's request for caesarean section or for a pain-free birth seems to have played an important role in the increase of caesarean and epidural analgesia's rates in past years [
5,
13‐
15]. Beckett (2005) argued that many women who choose cesarean section or epidural analgesia, may not be aware of the side effects of these interventions and are prone to make choices based on insufficient information [
5]. Moreover, women who choose hospital births and obstetric technology seem to do it out of concern for their baby's safety [
14]. According to Davis-Floyd (1994), American women who opt for the highest level of medical technology at birth, view these interventions as a form of control and empowerment over birth, rather than a loss of autonomy over it [
16]. On the other hand, the attitude and beliefs of the maternity care professionals towards childbirth and the way they see birth may have the greatest impact on childbirth care, specifically humanized birth care. Klein and colleagues' study on the attitudes of Canadian maternity care practitioners towards labour and birth [
17] showed that the family physicians who practice intrapartum care, as well as nurses, had intermediate score towards using obstetrical technology; however, obstetricians and family physicians who provide only antenatal care had more positive attitudes towards technology. Another study by Klein et al [
18] showed that younger obstetricians were more pro-technology in normal birth, including routine epidural analgesia, and less supportive of women's control on their own childbirth.
The preliminary findings of our study revealed that the humanization of birth in a highly specialized university-affiliated hospital is in fact perceived through a different set of key concepts, these being: security or safety, reassurance, and comfort. These concepts were actualized by taking into account access to modern technology, high levels of monitoring, and professional expertise. In the studied institution, personalized care, women's advocacy, companionship, reception of continued physical and psychological support by health care providers in a family-centered context, were shown to be the best advocates of humanized birth care.
Considering the fact that a significant proportion of high-risk pregnancies currently receive care in highly specialized hospitals; and that an important number of low risk women also seeks care in these hospitals, it becomes important to understand and explore the factors which may influence the childbirth experience in these hospitals, particularly, the concept of humanized birth care. The humanization of care in a specialized hospital cannot be achieved if the external organizational factors, or its internal components are conceived separately [
19].
We used the organizational culture model introduced by Allaire and Firsirotu (1984), in order to explore which of the external factors (history, society, contingencies) and the internal components of the institution (structure, culture, individuals) could act as barriers or facilitators to the humanization of birth practice in such hospitals. The authors considered the key concepts of humanization of birth as mentioned above.
The main research question was: in a specialized and university affiliated hospital, which internal and external components of the institution act as facilitators or barriers for adopting a humanized childbirthing care?
Methods
Study Design, Setting
The design is a case study involving a single hospital. The selected case is a highly specialized university-affiliated hospital in Montreal, Quebec, Canada, with 450 beds, including 30 beds at the Intensive Care Unit. Nearly 3900 births take place in the hospital every year, and the rate of caesarian section is approximately %29 of all deliveries [
20]. The reputation of the hospital in providing care for women at high-obstetric-risk made it a preferred tertiary level referral centre for high-risk pregnancy patients (%40), preterm and very preterm births as well as sick children in the province of Quebec. Whilst many of women which had been referred to this institution were labeled as being at high-obstetric-risk, and thus needing specialized attention and intervention, there were the majority of women who were cared for, at the same hospital, but did not suffer from complications described as being at high-obstetric-risk.
The case study is composed of three key stakeholder groups: 1) administrators, 2) professionals, and 3) women and families.
The study sample consists of: 1) eleven professionals from different disciplines including: nurses, obstetricians, pediatricians, and anesthetists, 2) six administrators from different hierarchical levels of the hospital, including: executive client-program management, quality and risk-assessment management, management of clinical services, and nursing care management, and 3) a total of 157 women who gave birth in the center during the study period
The sample size of women was calculated to reach a confidence level of 0.95, a 2-sided interval, a standard deviation of 0.6 from a previous study (De Koninck, 2001), and a distance from mean to limit of 0.1 for a number of 139 participants. To cover the probability of drop outs, the total sample for this study was calculated to be 180 women.
The professional and administrative participants were chosen intentionally from different disciplines, and with varied levels of work experience. The women participants in the questionnaire group were chosen randomly from the total sample. Ten women were recruited to participate in the interviews with a broad diversity in pregnancy and delivery types.
For women, the inclusion criteria were as follows: at least 18 years- old, and able to speak, read and write in French or English (necessary for completing the questionnaire). They had to be within 24 to 48 hours postpartum, they had to have given birth in the hospital; and finally, they had to give their consent in order to participate. Exclusion criteria included women with intrauterine death -this was due to the fact that such a condition may influence the childbirth experience.
Data Collection
Data was collected through: in-depth, open-ended, semi-structural interviews; field notes; participant observations; a self-administered questionnaire, documents, and archives. This variety of data sources allowed the triangulation of the data from the mentioned sources, and thus allowed to obtain information on the individuals' behavior, not just their stated attitudes.
The interviews were conducted in French and lasted between forty and ninety minutes. The interviews were continued until saturation of data [
21]. All interviews with the women participants were voice recorded and conducted, by the primary author, in the women's postpartum hospital room. An interview guide was prepared based on the conceptual framework and literature review. This guide had initially been pre-tested and validated before being used through separate interviews with two professional nurses and two women in birthing centres. The interviews were later translated into English for publication
The self-administered questionnaire that we used had been developed in the context of a study that assessed midwifery practice in Quebec, comparing it to the standard obstetrical care provided in the province [
22]. The questionnaire was adapted for the needs of the present study and was written in both English and French. The questionnaire comprised four sections and ninety-four multiple-choice and open-ended questions. The questions covered the topics of maternity experience, health-related consultation habits, the pregnancy, and delivery and early-postpartum experience. Finally, the questionnaire also contained some additional personal and socio-demographic questions. The reliability of the questionnaire have been assessed by Cronbach's Alphas; its values ranged from 0.71 to 0.93 [
22].
Several activities were also carried out in our study in order to maximize the validity and reliability of the qualitative findings. These included methods: obtaining coefficient reliabilities (≥ 80), triangulation of data, ensuring referential adequacy, persistent observation, and prolonged engagement [
23,
24].
Ethics approval was obtained from the Health Research Ethics Board of Hospitals affiliated with the Université de Montréal. Informed consent was obtained from all the voluntary participants. The women agreed to allow the investigator be an observer during their labour and delivery, and in the early postpartum period. The women were informed that withdrawal from the study was possible at any time, that they had the right to refuse to answer any of the questions, as well as the fact that participating in the study would not in any way impact on the care to be received. Regarding data confidentiality purposes, the investigator used a code instead of the participants' name on the transcripts.
The data-collection period for this study spanned from October 2007 to March 2008, and it continued until a sufficiently rich description of the concept under study was achieved [
21].
Data Analysis
Qualitative Data Analysis
In all, twenty-seven recordings were transcribed
verbatim and checked for accuracy, then entered into the QDA Miner qualitative software (Package Version 3.2.3). The field notes gathered from the field visits, the observation sheets, and the archival and administrative documents were also entered into the same software. All transcripts were coded into their distinctive categories, and a deductive content analysis was subsequently performed. This deductive approach aimed to validate and build upon the conceptual framework and theory used for this study. Thus, initial coding began with the external and internal factors mentioned in Allaire's and Firsirotu's organizational culture theory, as well as some relevant previous research findings regarding the concept under study. Then, the investigator immersed herself in the data and allowed the themes and categories to emerge from the data [
25]. The data matrices were used to enable comparisons. A sample of matrices of the study shown in the data matrices were used to enable systematic comparison [
26].
Quantitative Analysis of Data
The concept of humanized care as identified through the questionnaire's data means that the care has been modified to make it more in conformity with a certain philosophy and it was seen as being: 'care which is adapted to women's needs, that reflects a trust in the woman's capabilities, that gives control to women over decisions and choices '. The concept of continuity of care was assessed as being: 'the consistency in the content of follow up, such as: information, advice, explanations, etc; and having 'no interruption in the care received e.g. different caregivers are seen; and care is a shared approach'.
Descriptive statistics (means and standard deviations for continuous variables and proportions of the categorical variables) were used to summarize the responses collected in the self-administered questionnaires. Special attention was paid to the description of the quality and quantity of services received in the hospital, obstetrical interventions and neonatal outcomes, as well as the woman's overall satisfaction with her birthing experience, and the control they thought they had over it. All statistical analyses were done using the SPSS software (version 16).
Discussion
Our findings showed that many of the components of the external and the internal environment of a highly specialized hospital can act as facilitating or barriers for the 'humanization of birth' approach.
To summarize, our findings showed that most of the high-risk and low risk women were generally satisfied with the care and services they received in the highly specialized hospital and they would return back to the same hospital if they had a choice. Our findings are similar to those of De Koninck et al (2001), in that approximately 88.5% of physicians' clients of in Quebec hospitals indicated that they wished to deliver in the same setting for birthing if they became pregnant again [
22].
One of the facilitating factors of the humanized birth practice in this highly specialized hospital was seen to be the hospital philosophy, and strategies, which had been founded on family-centered care. The family-centered care approach of this hospital had already opened a door for professionals to share responsibilities with their patients, whilst still caring for their health. Our findings showed that women and families in this hospital were respected, and received a personalized kind of care. Previous research had shown that many women, who were looking for a midwife caretaker, were concerned about the 'individual' or 'personalized' and 'family-centered' aspects of care. In Parry's study, women discussed the importance of their husband's involvement in their childbirth; and they expressed their feelings that their husband wouldn't have been nearly as involved if they hadn't had midwives [
27]. However, the findings of our study revealed that integrating family involvement, and providing family-centered care, is also achievable in a highly specialized hospital, and that this was in fact a facilitating factor for the humanization of birth in such a context.
In almost all of the reviewed literature, the humanization of birth is defined as the use of decreasing levels of medical intervention in the normal delivery process (Brunt, 2005; Davis-Floyd, 2001; Page, 2000). In contrast to this, the humanization of birth in a highly specialized hospital is not, however, perceived in this way. None of the low or high-risk women in our study, however, complained about the medical and technical care provided to them; and on the contrary, they found it to be a necessary element of a secure birth. None of the women expected the care providers to respect their bodies' physiologic capacity in giving birth without medical intervention. We have learned from the findings of this study that even though most of the women interviewed reported the positive experiences of childbirth, women in a highly specialized hospital are increasingly being faced with the medicalization of birth. The women participants valued technology and the specialization of care, and even considered it as a facilitating factor for the humanization of birth, as it brought them reassurance and comfort. It was clear for women that a highly specialized hospital had its own frame of reference or 'language', and a highly technical one, and women and their families acted in accordance with the values and technologies surrounding them. On the other hand, women and their chosen hospital had the same codes and language in care. In our study, almost all of the women participants expressed no concerns about a natural birth. This contrasts with women who chose midwives or birth attendants as their care providers and who gave birth in a birthing centre. These women exhibited a resistance to the medicalization of birth, and opted for a natural birth, as well as seeked for continuity of care [
27].
Moreover, our findings showed that women had an increased tendency to want to give birth in a specialized children's hospital, as they saw it as being the best place for the safety and security for their baby. This result was similar to one of the findings of Jimenez's study which revealed that for many of the women who chose hospital, it remained "the ultimate safe place to bring a child into the world"[
28]. Cindoglu's 2010 study also showed that almost all Turkish women opted for medicalization due to their concern for a safe birth [
14]. Our findings also was similar to the study of De koninck et al (2001), where safety was considered as an important criterion for the quality of care for physicians' clients at hospitals and many women said that "if something goes wrong, we are in the right place"[
22]. Hausman argued that the way birth is defined as a risky event, leads to the over use of medical intervention and technology by physicians, even in the case of normal births [
29]. The medicalization of birth has come about due to the view that pregnancy as a time of risk and danger for the woman [
30]. The women who prefer technology and who rely on medicine and obstetrics, are more likely to consider the medicalization of birth as a means of reassurance, a reflection of the technological society, or finally as a result of fear as to the outcome of their birth [
31]. Henly-Einion has recently argued that "the concept of choice does not appear to be between natural and interventional birth, but between normal medical labour and complicated medical labour" [
31].
Most of the participating women in the study felt that they could not go through labour and give birth whilst controlling their own pain. Thus, they requested an epidural analgesia in order that they may have a pain-free birth. Women found that epidural analgesia was a facilitating factor in the humanization of birth care. Our findings also showed that the presence of a companion and the emotional support provided by this companion, as well as the use of other methods of relieving of pain -such as massages and breathing- did not change women's decision to have an epidural. Noticeably, during the data collection period, there had been no whirlpool baths available in the hospital; however, during the last field visit to the hospital, this method of relieving pain was seen to be provided for the women. Nevertheless, most women still requested epidural analgesia for pain relief. Paradoxically, in Parry's 2008 study, it was found that the Canadian women who chose a midwife felt they were more empowered than ever, and that they had full control over their bodies. Comparing women's quotes from Parry's study: "I just get the feeling that I can do this, and it's really not that big of a deal" [
27], with the quotations of women from our study "I would not be able to deal with for a normal delivery, I am not capable. Without an epidural, I would not be capable of doing it; I am afraid of pain, I do not like pain, I would never be able", clearly shows the individual differences on these issues, as well as the variety of women observed in society, some of whom seek midwifery care, and some who choose highly specialized hospitals.
The literature indicates that women's fear of pain at birth is depended on how women are prepared for birthing during prenatal care or even how they are informed about it by surrounding people. Empowerment at childbirth is relevant to midwifery care as the support of midwives is one of the most fundamental factors in a positive childbirth experience and help women to being in control of their body, mind and choices. The lack of support and understanding for the fear among those who provide care during the prenatal period and lack of enough information about the physiology of pain make women more dis-empowered [
32]. Melender's study (2002) showed that elements like previous experience, knowledge, or uncertainty caused fear to be associated with childbirth. Having knowledge found to be a very important means of removing or alleviating fear (Melender, 2002). The women participants in our study received information regarding pregnancy and childbirth through different meetings and prenatal classes, but it seems that this information was not sufficient or supportive enough to overcome women's fears about birthing. In order to alleviate the fear of childbirth, and the feelings of loss of control experienced by women during labour and delivery, health professionals should focus on empowerment strategies, as well as preparing women for labour during prenatal visits, or even before their pregnancy. This would help women regain control over their bodies, reduce the level of distress they experience during labour and delivery, and thus avoid the overuse of medical interventions in birth, such as epidural analgesia, and cesarean sections.
The findings also showed that professionals and administrators in the highly specialized hospitals valued the humanization of birth, and were proud the reconciliation of medical intervention and humanistic approaches to care. The attitudes of maternity care professionals, means nurses, obstetricians and pediatricians towards childbirth practice were not limited to providing optimal care through the use of obstetric technology, but to provide both physical and psychological care for women and their families. The humanization of care could be achieved through the validation of human beings, and one step towards this is "allying technical and humane competencies in professional practices" [
33].
Our findings revealed that changes have been made -or are going to be made- to the physical environment of the hospital and the maternity wards, in order to prepare for its evolution into a natural birthing centre, as well as to provide a more pleasant environment for women and their families during their hospital stays. Nevertheless, there were also still many barriers present, and these included women's choice limitations, lack of good communication between professionals in different units of the maternity ward, and lack of communication between professionals in different work shifts and finally the presence of a lot of health care professionals raised questions on the issue of privacy and dignity, and continuity of care; then, these were also considered barriers for the implementation of a more humanized birth care approach. The finding of a recent Canadian Perinatal Survey achieved by Maternity Experiences Survey (MES), revealed that only one-half (49.4%) of Canadian women had received continuous care in term of support from the same provider during pregnancy and at birth, while most of the women (88.4%) believed that it was important to have the same provider [
34]. This is imperative if the stakeholders in health care system are to attempt to ease the present overload of work, and provide continuity of care ranging from the women's first antenatal visit to home visits after birth as well as offering psychological and emotional support to women. The collaboration between the Centre de Santé et de Services Sociaux (CSSS) that midwives are part of it, and hospital centres guarantees that not only the women receive continued care, but also they would have access to different services and professionals in hospitals. This is what will enhance their sense of security.
Mota et al. (2006) stated that the humanization of care should be constituted as a policy in the organization of the health care system, based on the principles and modes of relationships between professionals and clients, and between the different professionals and different units of the health care services [
35]. According to the national humanization policy in Brazil, humanization involves knowledge transfer between the health care providers and clients, as well as between professionals and the ways their teams work together [
36].
The strength and limitation of the study
Using a mixed quantitative and qualitative method of collecting data, and the collection of an excellent variation of samples provided a rich pool of data for this study. The interpretations of the findings are shaped on the basis of triangulation of four sources of data, as well as of our in-depth knowledge in this field. However, this study, as any other, has some limits. The findings cannot uncover whether these were the women's culture, and/or the culture of birth place, or if the availability of obstetric technology, and the easy access to epidural analgesia - which is covered with insurance policies- that resulted in the high rate of demand for epidural analgesia observed in the studied hospital.
We tried to describe the research methodology including sampling, methods, and analysis in detail, which was used - to increase the transferability of the findings. The nature of this study, however, does not allow generalizing findings, as they do not reflect the practices of all obstetrics departments, in all highly specialized hospitals, regarding the humanized birth care issue in the province of Quebec in Canada. The level of obstetric interventions in different hospitals could change according to the hospital's mission, the level of care offered in that setting, and the characteristics of its target population.
For future research on this topic, we suggest a comparison of the facilitating factors and barriers towards humanized birth in the highly specialized hospitals, in different countries, where, the culture of childbirth is different from what we experienced in Canada. The setting of the highly specialized hospitals should be examined further for the feasibility of introducing more options for women, and for their right to make choices, if it aims at improving the practice of humanized birth care. More research should thus be conducted in order to understand what options and choices are realistically available to pregnant women who come to a highly specialized hospital to give birth to their child, as well as the factors which women take into account when making these choices if there is a possibility for it.
Conclusion
The implementation of the humanization of birth practices in the highly specialized hospitals aims at making the experience of hospitalization more reassuring, comfortable, and pleasant, for women and their families. A high level of technology and expertise, as well as caring, family-centered and continuity of care are all necessary to ensure the provision of humanized care in such an institution. The studied highly specialized hospital considered a safe place for women and their child in the case of a need for immediate access to medical care and technology. The argument of medical intervention and technology at birth being an opposing factor to the humanization of birth was not seen to be an issue in the studied highly specialized university affiliated hospital. Providing a pain free birth and technical care in a humane manner is essential to cover the humanized aspects of childbirth care and ensuring the satisfaction of women and their families who seek care in a highly specialized hospital. From the finding of this study authors conclude that mothers, children and families must benefit of progress in obstetric technology, but still a balance between security and humanity is essential.
When the aim is to improve the humanization of birth care in the highly specialized hospitals, the question of educating more health care professionals and integrating more care providers, especially midwifery and psychiatric professionals needs to be addressed by the stakeholders in health care system and hospital administrators. The greatest distress exhibited by women in this studied setting, was due to their hopelessness in having a guaranteed place for delivery before the onset of labour. This is imperative if the stakeholders in health care system are to attempt to ease the present overload of work, and provide continuity of care ranging from the women's first antenatal visit to home visits after birth as well as offering psychological and emotional support to women.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
Four persons have fulfilled the conditions required for authorship. Author 1(RB) has coordinated the paper from writing its protocol, taking approvals, designing the semi-structured questionnaires, collecting the data, transcriptions, analysis, and redaction of the manuscript. Author 2(MH) supervised the project from beginning to the end, helped in implementing the research, helped in qualitative analysis and validate the methodology, and participated in drafting the manuscript. Author 3(LG) also supervised the project, participated in the design of the study and questionnaire development. Author 4(WF) helped in preparing the field of research and participated in drafting the manuscript. All authors read and approved the final manuscript.