The birthing partner as labour supporter

2.6.2.1 The benefits of birthing partners providing one-to-one support in labour

The systematic review by Hodnett et al. (2013) suggests that having a chosen husband/partner, family or friend (sometimes referred as lay supporters, but in this thesis as birthing partners) present in labour increases women’s satisfaction more than any other provider of one-to-one support. Rosen (2004) in part,

attributes the positive outcomes achieved with lay supporters to shared language and values and an allegiance to the labouring woman. Historically female

relatives/friends have cared for women in labour and birth (Pascali-Bonaro and Kroeger 2004). In some societies where resources are low and

husbands/partners are not permitted, female relatives/friends as labour

supporters has the potential to achieve one-to-one support in labour at a quicker pace than the increase of midwives and doulas (Martis 2007).

2.6.2.2 The accessibility of birthing partners to provide one-to-one support in labour

Western societies prior to the 1960s were opposed to involving fathers in the birth environment (Hildingsson et al. 2011). This contrasts to the present day where most western nation’s expectant fathers are encouraged to be involved and actively participate in their partners labour (Johansson et al. 2015). Globally countries such as Botswana (Madi et al. 1999), China (Cheung et al. 2010), Ethiopia (Teshome et al. 2007), Iran (Kashanian et al. 2009), Jordan (Khresheh 2008), Lebanon, Syria, Egypt (Kabakian-Khasholian et al. 2015), Nigeria (Oboro et al. 2011), South Africa (Brown et al. 2007), Russia (Bakhta and Lee, 2010) and Zambia (Maimbolwa et al. 2001) do not permit birthing partners to stay with women in labour. Birthing partners are an important resource especially when hospitals have shortages of staff which result in many women in labour being left

56 alone for long periods of time (Madi et al. 1999; Brown et al. 2007; Khresheh 2008).

In low incomecountries, birthing partners could be the only resource to help with simple tasks such as giving labouring women water to drink or calling for help when needed (Maimbolwa et al. 2001; Brown et al. 2007). In addition the presence of birthing partners has been shown to change the attitude of staff so that they are more forthcoming and friendly (Bruggemann 2007) and midwives are less inclined to use early interventions (Madi et al. 1999). The reluctance of health professionals to invite birthing partners within hospital premises has been due to fears of infection, lack of space, suspicion that the non-professional labour supporters may administer traditional medicine to labouring women, fear of being sued (Maimbolwa et al. 2001), inconvenience to staff (Cheung et al. 2005) and fear that the supportive skills of trained staff would become superfluous (Cheung et al. 2010). It has been suggested that labour supporters other than the midwife can make women feel tense, increasing adrenaline levels which thenhave a negative impact on women’s’ contractions in labour (Odent 2008).

2.6.2.3 The experience of birthing partners providing labour support

No research was found relating to fathers’ experience of providing one-to-one support in labour, but there were two metasynthesis of qualitative research (Steen et al. 2012; Johansson et al. 2015) that explored father’s experience of labour. The first study (Steen et al. 2012) selected qualitative data from nine countries (UK, Australia, Sweden, USA, Japan, Taiwan, South Africa, Finland, and New Zealand). The second study (Johansson et al. 2015) selected

qualitative data from eight qualitative studies and involved 120 fathers from four countries (England, Malawi, Nepal and Sweden).

The findings showed that most fathers want to be actively involved in their partners labour, but there were some that felt pressured to attend and actively take part; fathers recognised that preparation was required (Steen et al. 2012; Johansson et al. 2015), but classes were women focused and completed when it was difficult for men to get time off work (Steen et al. 2012). Fathers commonly felt inadequate in their ability to support their partner and particularly struggled with seeing their partners in pain; (Johansson et al. 2015); men wanted the decision making to be undertaken jointly (Johansson et al. 2015) which was reflected in the UK and Finland studies (Steen et al. 2012). Fathers provided

57 comfort by calming partners when they were distressed, using talking and body contact, and being their advocate; fathers with previous birth experiences usually felt more prepared; fathers were not always prepared for the theatre however (Johansson et al. 2015). A few fathers reported that the experience of watching their partner give birth can lead to sexual and psychological scarring that can last for years. Some psychological scarring was also caused by unexpected or pathological clinical events, or by men experiencing cruel and dehumanising behaviour by staff or witnessing such behaviour towards their labouring partner (Steen et al. 2012).

Fathers were anxious about risks to their partner and baby (Steen et al. 2012); being kept informed helped fathers feel safe and inclusive. Fathers recognised that midwives were best placed to make a significant difference to how they perceived their experiences of labour. Health care professionals were not always attentive to men's needs or provided them with a high level of support which caused men to become less involved and increased insecurities (Johansson et al. 2015). Fathers tried very hard not to convey their fears to their partners.

The findings from Steen et al. (2012) and Johansson et al. (2015) appear mostly associated with anxiety provoking situations in labour. I questioned whether there were studies regarding positive events that were pinnacle moments which father’s experience and could be supported by midwives when providing one-to- one support in labour. Reading the title of a survey from Sweden (Hildingsson et al. 2011) suggested a more positive perspective as the research aimed to

identify the proportion of fathers who had a positive experience of a normal birth and to explore factors relating to midwifery support that were associated with the positive experiences. The research included 595 fathers whose partners had a spontaneous vaginal birth. The findings showed that the majority of fathers (82%) reported a positive experience. Support, presence and information about the progress of labour were the three most important aspects relating to a

father’s positive birth experience. Support seemed to be more important however for first-time fathers than fathers who had previous children. Midwifery support helped equip fathers to support their partners. Presence was highly valued. Fathers who were satisfied with the midwife’s presence and the information provided were four times more likely to report a positive birth experience (Hildingsson et al. 2011).

58 Whether it is the presence itself, or what the midwife actually did in the room that created security was not apparent from the study. Presence has been found to be vital however even when the midwife was not speaking or physically doing something (Backstrom 2011). Some fathers experienced high levels of anxiety and worry when left alone for short periods of time with their labouring partner (Tarlazzi 2015) as fathers felt a sense of responsibility which created insecurity (Thorstensson et al. 2012). Fathers found it particularly distressful when their partner experienced an increase in pain or if something unanticipated occurred and a health professional was not present (Tarlazzi 2015). Less anxiety was experienced in the absence of the midwife if there was trust that the midwife would return if requested (Backstrom 2011). Other positive behaviours by midwives included being respectful in their actions and language, allowing fathers to ask questions during labour and scope for fathers to choose to get involved or stand back (Backstrom 2011). Fathers wanted midwives to be

welcoming with a smile, spend quality time, and explain the procedures that they performed, show respect and reassurance to their partners throughout labour (Sengane 2012). Overall the importance of emotional support was valued by fathers (Tarlazzi 2015).

Not all fathers wanted to be present in labour and this appeared more prevalent in countries where the presence of the father is not the cultural norm. A

descriptive cross-sectional study from Zambia using semi-structured interviews of 385 men showed that 55% of them would be willing to escort their wives to hospital, but 99% reported that they would not be present for the birth (Ngoma 2013). Some of the contextual information in studies provided clues to why some fathers may not want to stay with women in labour. In some low income

countries there is sometimes no privacy so many women in labour are within one space (Chimwaza 2015; Kabakian-Khasholian et al. 2015) which some men will find personally or culturally unacceptable to be in the presence of other women giving birth. In addition, professional involvement during labour and birth is dominated by women and this has been identified as a source of discomfort for fathers (Chimwaza 2015). It has been argued that fathers should not be

expected to fulfil the role of primary labour companion (McGrath and Kennell 2008) as they can feel overwhelmed by a mixture of helplessness and

responsibility which can be detrimental (Backstrom and Wahn 2011). Fathers and female relatives/friends usually do not have experience providing labour

59 support and therefore need support themselves (Nolan 2010; Hodnett et al. 2013).

2.6.2.4 Training birthing partners

The evidence for training fathers to be labour supporters is contradicting when looking at qualitative (Tarlazzi 2015) and quantitative research (Wockel et al. 2007). Despite attending at least one meeting of a prenatal course each, all fathers interviewed said they were not really well-prepared for what happened during labour (Tarlazzi 2015) while others received training for the labour and they felt more prepared and positive about the labour experience (Wockel et al. 2007). Training needs to be delivered however at a time that fathers can attend (Steen et al. 2012) which may mean that separate training sessions are

organised for fathers (Wockel et al. 2007).

2.6.2.5 Women’s perspectives of birth partners acting as labour supporters

The majority of women want their husband/partnerpresent (Magee and Askham 2007; Dahlen et al. 2008; Cheung et al. 2010) and this is reinforced in the UK as 95% of women had their partners or companions with them in labour when they wanted them (CQC 2013). Women felt more in control and not alone when their husband/partner was present due to the emotional support as it boosted their self-confidence to cope with the labour pains (Sapkota et al. 2011).In countries where birthing partners are not permitted such as Saudi Arabia, 55% women did not want their partner present (Al Mandeel et al. 2013). This may indicate a cultural link influencing women’s preference in relation to the attendance of birthing partners.

Not all women wanted a labour supporter who they knew, due to concern about how that person would react to seeing them in pain, embarrassment and anxiety that the labour events may not stay confidential within the labour room

(Maimbolwa et al. 2001).Some women felt that their husband/partnermay lose sexual attractiveness towards them, women also had general concern for their partner’s wellbeing (Maimbolwa et al. 2001; Bakhta and Lee 2010; Oboro et al. 2011; Sapkota et al. 2011) and guilt from getting annoyed at their

husband/partner (Sapkota et al. 2011). A UK survey showed that 26% of women felt birth had a negative impact on their partner (Birthrights Dignity in Childbirth Forum 2013), and that the negativity increased if the woman experienced an

60 instrumental birth or she was a first time mother (Birthrights Dignity in Childbirth Forum 2013).

Long term benefits of the presence of husband/partnerwere found in a study from Nepal (Sapkota et al. 2013). The study compared continuous labour support by a husband/partner, female friends verses no support by any companion. The perspective of women was investigated using questionnaires postpartum. The results suggested that when the continuous labour support was completed by the husband/partner, the benefits were increased due to the long term relationship extending postpartum. Consequently women who had received continuous labour support from their husband/partnerperceived that they

received greater postnatal support at home which lowered their anxiety levels and had a positive impact on their mental health including their emotional well- being (Sapkota et al. 2013).