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Exploring the strategies that midwives in British Columbia use to promote normal birth Butler, Michelle M Jun 5, 2017

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RESEARCH ARTICLE Open AccessExploring the strategies that midwives inBritish Columbia use to promote normalbirthMichelle M. Butler1,2AbstractBackground: Rates of normal birth have been declining steadily over the past 20 years, despite the evidence of thebenefits to mother and baby. This is most obvious in steadily increasing caesarean section rates across countriesand studies of the factors involved suggest it may be more to do with the organization of maternity care and thepreferences of healthcare providers than changes in maternal or demographic conditions. The proportion ofwomen in British Columbia (BC) receiving care from a midwife continues to grow and there is a particular focus onpromoting and supporting normal pregnancy and birth in the midwifery philosophy of care. In BC, womenreceiving care from a midwife are less likely to have a caesarean section and other birth interventions.Methods: An interpretive approach, based on interpretive phenomenology was used to explore the experiences ofmidwives in BC of normal birth and the strategies that they use to keep birth normal. Fourteen experiencedmidwives were purposively selected from across the range of practice, geographical, and rural/urban contexts toparticipate in depth interviews. Data were analyzed using Thematic Network Analysis.Results: Seven key themes were identified in the data: working with women from the early pregnancy, informingchoice, the birth environment, careful watching and waiting, managing early labour, helping the woman to copewith labour, and tools in the tool kit.Conclusions: Midwives in BC work closely with women from early pregnancy to prepare them for a normal birth,and as “instruments of care” they adopt a range of approaches to support women to achieve this. The emphasis oncontinuity of care in the BC model of midwifery care plays a vital role in this.Keywords: Midwifery, Normal birth, Interventions, Caesarean section, British ColumbiaBackgroundIn Canada, the World Health Organization’s definitionof normal birth (see Fig. 1) has been accepted and ex-tended to also include the opportunity for skin–to-skinholding and breastfeeding in the first hour after thebirth, and evidence-based interventions in appropriatecircumstances to facilitate labor progress and normal va-ginal delivery [1]. Although there is concern about theunnecessary use of all interventions in labor, the majordebate in Canada, as elsewhere, is on Caesarean section(CS). CS is seen to be at the pinnacle of interventions,often resulting from earlier technical interventions thathave had unintended effects, that subsequently need tobe addressed with further interventions. This is often re-ferred to as the “cascade of interventions” [2]. Currently1 in 5 women in the world give birth by CS [3]. CS ratesin 2014 were 27.5% in Canada [4] and 32.4% in BC [5]and have risen steadily from 16.0% (Canada) and 17.9%(BC) in 1980 [6] (see Fig. 2).While CS will be essential in some cases to achieve a safeoutcome, the real concern is about the growing rate of un-necessary CSs and its impact on women and their infants.For example, CS is associated with higher rates of maternalmortality, morbidity, infection, hemorrhage, thrombosis,and complications in subsequent pregnancies. For the in-fant, it is associated with increased mortality and morbidity,Correspondence: Michelle.butler@ubc.ca1Department of Family Practice | Midwifery Program, University of BritishColumbia, 320 – 5950 University Boulevard, Vancouver, BC V6T1Z3, Canada2Faculty of Science and Health, Dublin City University, Glasnevin, Dublin 9,Ireland© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Butler BMC Pregnancy and Childbirth  (2017) 17:168 DOI 10.1186/s12884-017-1323-7admission to neonatal unit, respiratory distress syndrome,and difficulty bonding and breastfeeding [7]. More recently,studies have raised concern on the association of CS withlonger-term chronic conditions such as asthma, diabetes,cancer and obesity and on stem cell epigenetics [8, 9]. It isestimated that an appropriate CS rate is between 10% and15%; rates above 15% “may result in more harm than good”[10]. From a health systems’ perspective, there is also con-cern about the costs that unnecessary CSs impose on finan-cially stretched health systems [3].A taskforce established in British Columbia (BC) in2006 to investigate the increasing rates of CS concludedthat although the factors that are often blamed on in-creases in CS rates such as older maternal age, hyperten-sion, diabetes, obesity and multiple pregnancy hadincreased, “the rate of caesarean birth is rising faster thanmedical or demographic conditions would justify” [11]. Inthe UK, Marshall et al. [7] had similar findings and con-cluded that “the most likely reason for variation in rates isdifference in thresholds for intervention and variations inpreferred models of care at institutional and practitionerlevels” (p.333). A systematic review of strategies to reducethe rate of Caesarean birth in low-risk women [12] con-cluded that no single strategy was uniformly successful inreducing CS but the evidence was weak—suggesting moreresearch is needed to begin to identify effective strategiesto reduce CS. A systematic review of non-clinical strat-egies to reduce CS [13] also highlighted the limited re-search evidence available.Midwifery was established as a regulated profession inBC in 1998 and demand for care from a midwife con-tinues to grow—in 2015, 21% of women had care with amidwife [14]. Midwives in BC work as autonomous pri-mary care providers and the midwifery model of careFig. 1 Definition of normal birth in CanadaFig. 2 Caesarean Births in Canada and BC, 1980–2014. Source: CIHI [4], PSBC [5], Statistics Canada [6]Butler BMC Pregnancy and Childbirth  (2017) 17:168 Page 2 of 12emphasizes continuity of care and informed choice, in-cluding choice of place of birth. The midwifery philoso-phy emphasizes pregnancy and birth as normal andprofound life experiences and the role of the midwife inkeeping birth normal [15, 16]. Studies conducted in BChave shown that women who receive care from a mid-wife at home or in hospital, are less likely to have proce-dures during labour such as caesarean section, narcoticsanalgesia, electronic fetal monitoring, amniotomy, andepisiotomy, compared with women who give birth inhospital attended by a physician [17–19].Continuity of care is a key and deliberate feature of themodel of midwifery care in BC and to achieve this, mid-wives work as solo practitioners or in teams of up to fourmidwives, each midwife can provide care for a caseload ofup to 60 women each year, and each midwife is compen-sated per “course of care” through the province’s universalhealth insurance (Medical Services Plan). Each womanwill see her midwife several times before the birth at visitsthat last for about 45 min. Most women who have carewith a midwife will know the midwife who attends themfor the birth and women have the choice of place ofbirth—hospital, home, or another appropriate setting.Women receiving midwifery-involved care (a midwife wasinvolved in their care but may not have been the deliveryprovider) in BC in 2014/15 were more likely to have a va-ginal birth (79.7% versus 67.6% for all care providers) andless likely to have a caesarean section (20.3% versus 32.4%for all care providers) [14, 20].This study set out to examine the experiences of mid-wives in BC of normal birth, the challenges that they ex-perience to keeping birth normal and the strategies thatthey themselves use in their practice.MethodsAn interpretive approach based on interpretive phe-nomenology and involving in-depth interviews, wasused to explore midwives’ experiences of promotingand supporting normal birth (see Additional file 1 forthe interview guide). This approach enables the re-searcher to create a “dialogue between practical con-cerns and lived experience through engaged reasoningand imaginative dwelling in the immediacy of the par-ticipants’ worlds” [21] (p.99).SampleOn the basis that the context of practice in BC would beimportant in relation to the challenges that midwiveswould experience and the strategies that they would use,midwives with at least 5 years’ experience as a midwifein BC were selected from a list of registered midwives,to reflect possible variations in experiences betweenmidwives working in urban and rural locations acrossBC (lower mainland, Vancouver Island, the interior andNorthern BC), and between those working as solo, mid-wifery group and collaborative practitioners (midwivesand family doctors sharing a caseload). Following ap-proval from the university Behavioural Research EthicsBoard, 16 midwives were approached, provided with ver-bal and written information on the study and 14 con-sented to participate.Data collectionInterviews provide “a unique access to the lived world ofthe subjects, who in their own words describe their activ-ities, experiences and opinions” [22] (p.10). Individualsemi-structured interviews were used for this reason andto enable the researcher to further explore and seek clarifi-cation around themes raised by participants. The majorityof interviews took place face-to-face in midwives’ place ofwork or home, two interviews were conducted on Sky-peTM and two were conducted by telephone. Interviewslasted for between 45 min and an hour and were recordeddigitally. Recordings were transcribed for analysis. Inter-views began by exploring what midwives understood bythe term normal birth, participants’ experience of normalbirth in their daily practice as midwives, any particularchallenges they experience and the strategies that they useto maintain normal birth. The focus of this paper is on thestrategies that midwives used to maintain normal birth.AnalysisThematic network analysis [23] was used to reduce andexplore the text, and to integrate the themes identifiedin this exploration. The process began by the researcherreading transcripts to become very familiar with thecontent and identify patterns in the data. On subsequentreadings codes were applied to the data to reflect thethemes emerging (basic themes). Similar themes weregrouped together to form categories (organizing themes)and these were further clustered to form global themes.In this way, the data were explored, thematic networkswere constructed and explored, and patterns were sum-marized and interpreted.ReflexivityBerger [24] describes reflexivity as a “process of a con-tinual internal dialogue and critical self-evaluation of[the] researcher’s positionality as well as active acknow-ledgement and explicit recognition that this positionmay affect the research process and outcome” (p.220).There will be several potential sources of bias in qualita-tive research, given the close connection between the re-searcher and participants and the use of the human asinstrument [25]. These include power imbalances, andperceptions and misconceptions about roles and inter-ests in the topic being researched. In this study, the re-searcher was a midwife but had not practised in BC andButler BMC Pregnancy and Childbirth  (2017) 17:168 Page 3 of 12occupied a leadership position in academia. To minimizeany biases that could arise, the research process involvedboth prospective (thinking about how the researcher in-fluenced the participants) and retrospective reflexivity(thinking about how the participants influenced the re-searcher) [26]. From the prospective perspective, partici-pants were informed in invitation letters of the purpose ofthe research, why they had been selected to participate,that they were under no obligation to participate in theresearch, and were assured of their anonymity. Before be-ginning interviews, participants were again assured of theiranonymity and encouraged to be open about their experi-ences. From the retrospective perspective, an open ques-tioning style was used in interviews and ideas and issuesraised by the participants were returned to them for furtherprobing. The researcher was careful to seek clarificationsabout assumptions made and to keep participants’ viewsseparate from her own opinions and presuppositions.Interview transcripts were analyzed using software (NVivo,Version 10.2.1, QSR International Pty Ltd.) to allow all datato be dealt with systematically, to keep an accurate recordof the themes identified, and to keep memos of observa-tions that emerged in the course of analysis.ResultsThe 14 midwives who participated in the study werefrom across the range of practice types, urban, rural andremote contexts, and geographical locations in BC andnine participants had more than 10 years experience asmidwives (see Fig. 3).Interviews began by exploring midwives understand-ings of the term normal birth. Eleven of the fourteenmidwives interviewed raised concerns with the term nor-mal, suggesting the term was academic, only classifiedafter the fact, or culturally defined. Eight midwives pre-ferred the term physiologic, and seven midwives referredto normal birth as an outcome and spoke about workingtowards a normal vaginal birth.Two midwives described how what they considered tobe normal shifted over time:To be honest I feel like I had a really clear definition atone point. It was really clear to me that normal birth wasno intervention, healthy woman, healthy baby… I feellike my definitions are shifting quite significantly in termsof what is a normal length of birth, what is the normallength of pushing… why if everything is going well andbaby and mum, mum and baby are doing fine, then canwe stretch those meanings of normal a little bit more?Six midwives spoke about the importance of experienceand confidence in their ability to support a normal birth.They talked about how, over time, they became moreconfident to work to keep the birth normal and to ques-tion procedures and protocols that work against normallabour. They also spoke about the benefits of their experi-ence in terms of developing a range of skills to deal withdifferent situations and in terms of being more tuned intowhat is happening in particular scenarios.Strategies used by midwives to keep birth normalParticipants identified and discussed the particular strat-egies that they used to keep birth normal. Seven key orga-nising themes were identified relating to: 1. Working withwomen from the early pregnancy, 2. Informing choice, 3.Managing early labour, 4. The birth environment, 5. Care-ful watching and waiting, 6. Helping the woman to copewith labour, and 7. Tools in the tool kit (see Fig. 4).Working with women from the early pregnancyEleven midwives talked about working with the womanfrom early pregnancy towards a normal birth, forexample:Fig. 3 Participants (n)Butler BMC Pregnancy and Childbirth  (2017) 17:168 Page 4 of 12I have this expectation for every delivery that I go tothat it will be normal in the end. There may be littlechallenges here and there but that’s what my experienceand training is for, to overcome those challenges andstill allow women to have a vaginal delivery. Of coursethere are some cases that are different, you know if thereis major pathology then of course, I have to let go of thatexpectation but throughout, or let’s say from the firstday that I see a woman that’s what I work towards. Ihave 9 months so it’s quite a bit of time to prepare herand myself getting to know her, have a good deliverywith you know a vaginal birth in the end and no majorcomplications.A key theme in all of this was on-going education:We do a lot of prenatal education, we talk a lot aboutwhat labour looks like, how to prepare for it, we talk tothe partners about how to support them in labour, wetalk about all the different kind of managementtechniques and comfort measures and we talk to themabout pain relief options all the way from non-pharmaceutical to pharmaceutical and epidurals andwhat’s available … so I really prepare them for the ideathat we’re going to do a lot of this outside the hospitaleven if they’re planning a hospital delivery that theyhave the tools and the resources that they need to copewith labour, that labour’s a very normal thing and uh,we make sure that we’re available to them.One midwife referred to anticipatory guidance, wheremidwives provide women with timely and clear informa-tion, so that they know what to expect and becomeconfident in how they will deal with different scenarios.Another midwife referred to changing women’s percep-tions over time and on-going reinforcement of birth as anormal event. Three midwives highlighted the need towork with women to create realistic expectations. Partic-ipants referred to working with the woman to addressproblems in their lives that are likely to impact on thebirth and focusing on the woman having a healthy preg-nancy so that they would be physically fit for labour andbirth. It was also suggested that the longer prenatal ap-pointments that women have with midwives is helpful inbeing able to provide this information.Informing choiceMidwives spoke about the challenge involved in provid-ing balanced information to women so that they canmake an informed choice, while also supporting normalbirth. They spoke about presenting the evidence andguidelines, and supporting women to make informedchoices. They suggested it is easy to be hands-off wheneverything is going to plan but there is a particular chal-lenge in informing choice when problems arise forwomen who do not want interventions. It was suggestedthat women should be supported to have appropriate in-terventions in labour, if they will benefit the woman:[If] she’s communicating that she’s really really tired, Ihave this you know gut feeling that if I rupture hermembranes things are going to move really fast andthere’s going to be a baby and she can just snuggle herbaby and go to sleep then that may be an interventionI use in that moment, as something I might offer herand explain it that way, “it’s an intervention, it canFig. 4 Strategies that midwives use to keep birth normal along the care timelineButler BMC Pregnancy and Childbirth  (2017) 17:168 Page 5 of 12help things move along quicker, is that something youwant to try?”. These are the risks and benefits.One midwife highlighted the importance of being au-thentic and women having a choice even if it is not tohave a normal birth, for example a woman wanting anelective caesarean section. Three participants referred toproviding honest information so that a woman can makean informed choice around induction:I’ve had people say things like when you get to42 weeks your risk of stillbirth will double and thenjust leave it at that, whereas we’re very conscious tosay well yes your risk of stillbirth will double but thisis what it is doubling from and to and these are theactual stats, these may be some other factors to bearin mind when you’re making this decision. So Isuppose it’s about using the information accuratelyand not using it in a frightening way or a way to beable to coerce women into what would be thecommunity standard. So you know if I just stop atyour risk of stillbirth doubles at 42 weeks, what sanewoman wouldn’t choose to be induced but if we thengo onto say what that actually involves then I wouldfind, we have a very low induction rate compared tosome places.One participant highlighted the importance of balan-cing the aim of achieving a normal birth with other pri-orities that women have, for example when providingcare for a woman with a history of trauma or intimatepartner violence.Managing early labourParticipants spoke about the importance of managingearly labour well, so that women are in a good positionto go into active labour. They spoke about preparingwomen for what to expect in early labour and how toprepare for it:… we talk a lot about what labour looks like, how toprepare for it, we talk to the partners about how tosupport them in labour, … especially for the primips …that prodromal labour stuff I mean that’s a mentalgame and that’s why a lot of women end up in thehospital too early, so we do, we do a lot of homesupport for that and phone calls and making surethey’re well prepared for that and coping with that …when I’m talking with them prenatally about whatearly labour looks like versus active labour.Midwives also talked about how they support thewoman to get some rest and to eat and drink in earlylabour so that they are ready for active labour:… I really emphasize very strongly with my clientsabout how to manage their early labours and sleep inearly labour and I encourage them to consider Gravol[Dimenhydrinate] … for sleep, even like I saidcertainly the first night if they’re starting early labourat night and even sometimes the next day like late inthe day or early in the evening, if they’re taking theirtime. I just find that rest can have a huge effect inbeneficial ways and also making sure that they eatand drink and making sure that they, hoping andhelping them to ignore as much as early labour asthey can.Encouraging women to stay at home for as long aspossible was a particular strategy used to keep birth nor-mal, and to reduce the likelihood of interventions:Well I think there’s research to show that the earlieryou go into hospital the more likely you’ll end up withintervention cascade so one of the things I try to do,because we’re watching more and starting todocument more, if they’re in a big hospital system,then I think there’s more of a tendency and I thinkmidwives are no different, as a practitioner you kind ofthink you have to be doing something whereas at homeyou can go listen to baby, do the blood pressure, listenyou know and reassure and make sure she’s eatingand drinking but it’s not so much okay now we’regoing to do a check again in 2 or 3 or 4 h for a vaginalexam and see if there’s any progress when you’restarting at, you’re not really in labour. So let labourestablish itself before you start thinking there shouldbe progress …Five midwives talked about the value of visitingwomen at home in early labour to assess, reassure andsupport them.The birth environmentParticipants spoke about the importance of the birth en-vironment to supporting normal labour and birth. Mid-wives suggested that the home was the place that wasmost conducive to having a normal birth and in somehospitals birthing rooms were available with pools and alow-tech environment. However, participants also talkedabout how they would try to create an appropriate low-tech, home-like environment, even in other more trad-itional maternity hospital settings:I feel like whenever I can actually get people to havebabies at home or if we do go to the hospital have ahome birth in the hospital—meaning we don’t use alot of the technology in the room and we push it out ofthe way and we kind of keep to ourselves a littleButler BMC Pregnancy and Childbirth  (2017) 17:168 Page 6 of 12bit—we can have a home birth in the hospital andsome women will end up with these magical amazingbirths on the floor of the bathroom at the hospitalwhich is just as normal as the magical birth in the tubin the living room and it just happened in a differentenvironment but it’s because we didn’t engage with allof the rest of the equipment and I find what I need todo in those situations is because I’m experienced nowand people know me and I have a reputation, I canclose the door and the nurse can come in when I wanther to and I can ask her to come in.Seven participants talked about guarding the physicaland social space for the woman. Some participantstalked about protecting women from other hospital staffwho might want to intervene, whereas other midwivestalked about how they had built up important relation-ships and trust with hospital staff over time so that theydid not interfere in women’s care. They also talked aboutprotecting the woman’s privacy and helping her and herpartner to manage the expectations of others and thepressures arising from social media:I feel that women and their partners do muchbetter with privacy and intimacy during the birthprocess and that, my role is to sometimes protectthat privacy and intimacy first of all by educatingthem that that might be really important and totalk about you know the effect both positive andnegative about um, support during that time can beor even just letting people know hey, we’re inlabour, the Facebook kind of thing but you knowkeep it quiet, keep it down, don’t fritter the energyaway by drawing other people to it or drawing theexpectation that something’s happening rather thanjust letting something evolve … I think guarding thespace by keeping the space as calm and quiet andprivate as possible is key and giving people tools todo that during the prenatal time to deal with overeager family members or friends.A related theme highlighted in the data was the im-portance of the woman having support from a partner,friend or doula:Try to make sure she’s well supported so for examplewith our teen clients that’s not always, well with anyclients, but specifically with our teen clients that’soften not the case. It’s often the case that they are notwell supported. So they may or may not have thepartner in the picture, they may have an estrangedrelationship with their parents. I would say more sothan on the average other clients we have so for themwe make sure that we get them doulas, we make surethey have doulas and we do a lot more intentionallabour work with them.Careful watching and waitingParticipants referred to their role in quietly monitoringprogress and taking small steps from time to time to ad-dress issues as they arise, in order to nudge things backto normal:I think the most important thing from myperspective is that my grounding in normal helpsme recognize the abnormal … it’s like a line, thestraight line of normal and if there’s a wavering offto one side or the other you just try a little tinysubtle intervention to nudge it back to normal …like if the baby is malpositioned you know, ideasand ways, and position changes, manoeuvres wecan do to try to get the baby into a better position,things like that … so you know if she’s dehydrated,hydrate her. If she’s tired give her some food, youknow, those kind of things … if it’s gettingtachycardic and you hydrate mum and you cool heroff, if she’s in the tub you cool her down, get herout of the tub, those little nudges and then quiteoften it normalizes, stabilizes and then you’re notcreating a problem.Three midwives referred to limiting the number of va-ginal examinations they conduct in labour, preferring tomonitor other signs of progress in labour:And so part of that is I do think doing a vaginalexam in and of itself is an intervention that canslow things down for the mom … and now I reallythink about why am I doing this? What informationam I going to get? Things like that and I do thinkthat helps keep things normal because you’re doingless unnecessarily vaginal exams which is anintervention.One midwife referred to having a quiet presence:I try to keep a fairly quiet presence, try to work outwhat the woman and her partner, or partners,whoever’s around her, are being able to sort of dothemselves … I think it’s probably better to let womengo into themselves if they want to do that, so trying tosupport the woman in the kind of personality andneeds that she has, and keeping that low-key presencewith things like monitoring being a subtle as it can be,and I don’t really care for doing regular VEs so it’smore about clinical indications or their impressionrather than it’s been 2 or 4 h since your last one sotherefore you have another one.Butler BMC Pregnancy and Childbirth  (2017) 17:168 Page 7 of 12Another midwife spoke about the importance of a mid-wife being really present to achieve a normal outcome:You have to be present and I think that’s one of thethings that keeps birth normal, we can go on and onabout all the tools and I think those are valuable, I’mnot saying they’re not, but I think that the message isyou can’t do it from a distance so you can’t be athome while someone’s labouring, get up come in anddo the birth. [If you don’t] You will have a highersection rate, so part of that is you need to be inattendance to keep the birth normal and some of it isjust to have an opinion about the strip, some if it isliterally where you feel like you’re standing guard, notagainst bad people but against keeping the space forthe woman private and without a lot of stuff going onaround her that’s going to distract her just being in herlabour. So that’s part of our philosophy as a team thatwe tell our patients … You don’t leave a womanpushing ever so I think constant presence, I’ve come tobelieve that that’s really important.Helping the woman to cope with labourParticipants talked about the ways in which they helpwomen to cope with labour. These included ensuringwomen attend prenatal classes, answering women’squestions candidly, being honest with women—not sugarcoating but not scaring, talking with them about therange of pharmacological and non-pharmacologicalmeans to manage discomfort and pain in labour, and en-suring women have arranged good support (someone tobe with them) for labour:… you know a lot of it is attitude like I say and goingthrough the positive part of pain in labour and, andusing your rest periods really effectively, not gettingahead of yourself, trying to just stay in one contractionat a time and I teach them that prior to labour but Ialso reinforce that a lot in labour and then comfortmeasures like water, we have great showers in ourhospital, we don’t have tubs which is unfortunate butit is true the hot water never stops running so lots ofmy clients spend long times in the shower and differentposition changes and heat and ice and all of thosethings that we can use. I definitely like to use all ofthem—the ball, going up and down the stairs.Midwives also spoke about the need to consider thewoman’s ability to cope and that sometimes it is toomuch to expect the woman to go without interventions:I always have held this in my heart—don’t sacrificethe relationship between the mother and baby becauseyou want the woman to have a completelyunintervened birth. I’ve seen that many times where amom is so miserable by the time she has her baby andso exhausted and so out of it that she’s not even happyto see her baby when, you know as you become moreand more experienced you realize there are ways thatyou can help that to be avoided.Two midwives talked about offering a woman an epi-dural if she gets to the point where it appears she cannotdo it anymore, or where the woman has crossed the linebetween pain and suffering:But then the other situation is really straight up forpain relief when I, most of the time, when I wouldrecommend an epidural is when I see, and am Iwondering if that woman is crossing the line betweenpain and suffering. And so I, when I do offer that Icould offer it very judicially and very gently but Iwould say something like “what I’m seeing here is this,I’m wondering if you might benefit from some painrelief” and basically either they jump on it or they’relike “no, no, I can manage”.Tools in the tool kitThe final cluster of themes related to different tools thatmidwives gather as they become more experienced andthat they use in different scenarios to keep birth normal:It’s like tools in your toolkit and you’re filing thataway and it’s like that idea of lifelong learning, you’realways going to be adding tools to your toolkit, youshouldn’t let it get full of cobwebs like you need to keepadding to it because there’s always something that’sgoing to work and make it a little change and for methe mechanics of it … and understanding all of thosemechanics and bringing that to the mechanics of thepelvis and how babies come down and all of that andso there is a part of me that kind of, I can think it’svery cool that there are ways that this baby can comedown and the more experience you get the more yourealize yeah we can nudge this a little bit. Change thatposition, tilt, do this, do that.Midwives referred to a number of interventions thatthey used wisely to keep birth normal:… we can run into little obstacles on our way andthere are tools available and mostly they are myclinical skills but occasionally I suggest an epiduralor maybe the patient really demands one and Ihave not enough to offer that she can do without,yeah of course, interventions need to be used wiselyin order to achieve that goal … So I’m open toanything … I use a lot of alternative, I pretty muchButler BMC Pregnancy and Childbirth  (2017) 17:168 Page 8 of 12use any tool that is available, hopefully in the rightsituation to achieve that goal.Tools also included referring women for acupunctureand one midwife had basic training in acupuncture:I only have basic training in acupuncture so Isometimes do some, I sometimes send them to apractitioner … so I just do routine things like birthpreparation if, induction points, turning the baby if it’sa breech baby so I just do basic things … we havesome really good acupuncturist in town so I can sendthem out. I might use it in labour if her contractionsslow down. If she’s not letting go and just I go again alittle bit by my feelings and say okay this would benefither in this situation.One midwife referred to approaches she used for cer-vical ripening for women with a history of post-termbirth. Three other midwives referred to using labourcocktail or Verbena cocktail (a cocktail of castor oil andVerbena Officinalis) for the induction of labour:And a lot of that is about cervical ripping andstuff so with people who have a history of goingpostdates, I really encourage them to do stretchand sweeps and acupuncture and we do likecervical ripping tea and stuff like that. So we tryto help them get ready at least to help their cervixripen before we have to do something more seriousand then if they don’t have a history, like I wouldsay we do the same, basically the same thing. Wejust maybe leave it up to them a little more.Several midwives mentioned using water to helpwomen to cope with pain and discomfort in labour:… we have a high water birth rate here, mostlybecause we have this water birth room, which isavailable with tons of hot water and a big beautifultub and so essentially if I get them in the room, Iget them in the water, I’m listening to the baby, Ishut the curtains around the tub, I turn the lightsdown and I just give them that hour, like 1 to 2 hof kind of privacy where I’m sneaking in to listen tothe baby.One midwife referred to rupturing membranes torotate babies or to move the labour along. Othertools in the toolkit that midwives also referred to in-cluded ensuring the woman has adequate nutritionand hydration in labour, keeping the woman active,and homeopathy and hypnotherapy to help thewoman to relax and to reduce anxiety.DiscussionThe demand for midwifery care in BC is growing year onyear. The promotion of normal birth is a key part of themidwifery philosophy of care and women who have theirmaternity care provided by a midwife are less likely tohave a CS and other interventions. Recent research sug-gests care with a midwife is as safe as that provided by afamily physician or obstetrician, regardless of whether thewoman chooses to give birth with a midwife at home or inthe hospital [17–19]. The findings in this study provideconsiderable insight into the strategies that midwives useto achieve this.A key theme running throughout midwives’ accounts wascontinuity of care and the importance of the relationshipbetween the woman and her midwife and of the midwifeworking with the woman from early in her pregnancy to-wards achieving a normal birth. In the BC model of mid-wifery provision, the emphasis is on the woman seeing thesame care provider (midwife) for most of her care. Awoman may also see mostly the same provider if her care isprovided by a family doctor, but women attending forobstetrician-led hospital-based care may see different mem-bers of the multidisciplinary team providing that care. InBC in 2014/5, 51% of all women received their care froman obstetrician [20]. Key aspirations in continuity of careare woman-centred care, reducing the number of carers awoman sees, the midwife knowing the woman and thewoman knowing the midwife, a woman being cared for bypeople who are familiar to her and aware of her plans forher birth, and her care provider providing a high degree ofsupport in labour [27]. A systematic review of 15 trials [28]identified that women receiving care in midwifery-led con-tinuity models of care were less likely to experience inter-ventions and more likely to be satisfied with their care.Interestingly, the review found no impact on caesarean sec-tion rates. However, in the models of care that they exam-ined all women gave birth in the hospital setting.A key theme in the data was the importance of man-aging early labour. Early labour is a time of considerableuncertainty and it can be a very anxious time for women.Women may not know what to expect and they may needand seek reassurance about whether labour has startedand when to attend the hospital [29]. Midwives in thisstudy talked about the importance of preparing womenfor what to expect in early labour. They also talked aboutvisiting women at home in early labour to assess themand to provide reassurance. A randomised control trialconducted in BC [30] found home visits in early labour tobe more effective than telephone triage in reducing thenumber of women attending the hospital for assessmentbefore they are in labour and those attending before 3 cmcervical dilation, although the home visits had no impacton CS rates or birth outcomes. What is different withmidwives in this qualitative study is that the home visit inButler BMC Pregnancy and Childbirth  (2017) 17:168 Page 9 of 12early labour was not a single intervention but one part ofa comprehensive package of midwifery care in earlylabour. Midwives talked about a number of ways in whichthey help women to cope with early labour and ensurethey do not get exhausted before they go into activelabour, encouraging them to rest, mobilise, eat and drink.They reported recommending distraction, pharmaceuticaland non-pharmaceutical pain relief and comfort measures,and Dimenhydrinate (Gravol®) to help women to rest. InBC midwives may administer Gravol® under MidwivesRegulations [31], for its sedative effects for “therapeuticrest during prodromal or early labour, particularly whereanxiety is a factor” (p.40).Midwives also reported encouraging women to stay athome for as long as possible in early labour in order toavoid the interventions associated with hospital. Cheyneand Hundley [32] suggest this is not surprising given theuncertainty that practitioners experience around decidingwhether labour has started. They highlight that in the hos-pital the situation is fraught with anxiety, emotion, timepressures and competing priorities, and decisions areoften based on unclear or incomplete information. It isacknowledged that hospitals tend to be optimised forhigh-risk women—with technology and staffing for closemonitoring and quick access to interventions, and forlow-risk women—staff monitor and tend to intervenemore than is necessary [33]. This may result in avoidableharms to women and newborn while driving up the costsof maternity care. Miller and colleagues [34] use the term“too much, too soon” to refer to the over-medicalizationof birth following the rapid increase in the use of hospitalas the place of birth in high- and middle-income coun-tries, which they claim, might offset recent gains from im-provements in maternal and perinatal health. Theirparticular concern is the “trends towards excessive, un-necessary, or inappropriate use of obstetric interventions”(p.2178), including unnecessary ultrasound examinations,routine electronic fetal monitoring, routine episiotomy,high rates of labour induction and augmentation, andnon-medically indicated CS.The findings also emphasise the importance of womenhaving a supportive birth environment and althoughmidwives suggested that the optimal place of birth to fa-cilitate normal birth is at home, they also described howthey were able to adapt a hospital birthing space to fa-cilitate normal birth and suggested that it is the respon-sibility of the midwife to protect the birth space,regardless of where the birth takes place. A qualitativestudy in Australia [35] highlights the medicalised envir-onment in the hospital setting and its associated “bio-medical discourse with an emphasis on risk” and howthis can hinder the midwife’s ability to facilitate normalbirth. There may also be a pressure to conform in thisenvironment and difficulty challenging practice that isnot evidence-based. Specific strategies that midwivesused in that context to facilitate normal birth included“making a safe place for women and guarding the door”to exclude medical staff who may be inclined to takeover at any time.Fahy and Parratt [36] refer to the ideal birthing envir-onment as the “sanctum”—a homely, private environ-ment where the woman feels at ease and comfortable.The environment is familiar and feels private and safe,and has easy access to a bath, toilet and the outdoors.This environment supports “the woman’s embodiedsense of self”, optimal physiological function and emo-tional wellbeing. They contrast this to the “surveillancespace”—filled with equipment, dominated by the bedand lacking privacy, and suggest that the further thebirth space is from the sanctum, the more likely thewoman is to feel fear. Fourneur and colleagues [37] pro-vide a comprehensive review of the research relating tothe bio-behavioural system in labour to show how stressand fear in labour mediates the release of endogenousoxytocin, which can hinder the progress of labour, infantattachment and feeding. In another paper, Fourneurhighlights the midwife’s role in guarding the birth spaceto ensure it is optimal for the woman and her baby. It issuggested that if the labour room has a technologicaltheme, this emphasises birth as a biomedical event ra-ther than a health event and can be a source of stressand fear for the woman. It is also suggested that the de-sign of the birth unit and the model of care are import-ant mediators in communication between a woman andher care providers and may also impact on staff ’s stressand quality of decision-making [38].The findings of this study also highlight that in thebirth space the midwife needs to be “really present”. Thisfurther highlights the importance of the relationship thatis developed between the woman and her midwife. Astudy of women’s negative experiences in labour [39]found the lack of presence (even though the midwifewas in the room) and lack of feeling supported by themidwife, to be a central issue in women’s negative expe-riences. Midwives in this study highlighted the import-ance of women having good support in labour, bothfrom a partner, family, and/or a doula and from the mid-wife. In the BC context, continuity of care from the mid-wife occurs across the full spectrum of care, includingthe birth. A systematic review of 22 studies [40] foundwomen who had continuous support in labour (eitherfrom a nurse, midwife, doula, childbirth educator, familymember, partner, or stranger) were more likely to have aspontaneous vaginal birth, a shorter birth, and to be sat-isfied with their birth.Perhaps the most significant finding in this study is thatmidwives judiciously employ a spectrum of interventionsto “nudge” labour and birth towards positive outcomes.Butler BMC Pregnancy and Childbirth  (2017) 17:168 Page 10 of 12This study highlights a number of interventions that mid-wives use to keep birth normal, dispelling the notion ofnormal labour and birth being free of interventions. Mid-wives clearly use interventions but these may not beregarded as medical or technological interventions. Astudy with exemplar midwives [41] describes midwivesusing themselves as “instruments of care” through theirpresence with the woman and using a finely tuned mix oflow- and high-technological interventions to meetwomen’s needs. This mix, the authors suggest, is the dif-ference between midwifery and medical models of care.The strengths of this exploratory study lie in the insightgenerated from the detailed accounts provided by mid-wives. This is the first study on this topic to be conductedin BC and the findings support to-date anecdotal accountsof midwives’ commitment to promoting and supportingnormal birth, some of the challenges they face, and identifya number of topics for further exploration. The limitationsof the research include the small sample size overall, andthat although the design aimed to allow for likely context-ual and practice differences across BC, the very small num-bers of midwives within each stratum further limits theapplicability of the findings. In qualitative research, deci-sions about the generalizability or transferability of findingsmust be made by the reader, but this relies on the re-searcher providing adequate information on the methodsand contexts used in the research [42]. The detailed exam-ples provided in midwives’ accounts may usefully assist thereader in this regard, but further research is required to ex-plore the topic more fully and to examine the impact of theinterventions identified (e.g. management of early labour,home visits in early labour, delayed admission to hospital,water birth, Verbena cocktail) on the progress of labourand birth outcomes. Further research is also required to ex-plore the experiences of other maternity care providers inBC (family doctors, obstetricians, and nurses).ConclusionsMidwives in BC have an important role in promotingand supporting normal birth as “instruments of care”.This begins early in pregnancy, working closely withwomen to prepare them for a normal birth, ongoingeducation, informed choice discussions and the man-agement of expectations. Midwives use a range ofmidwifery skills and midwifery interventions acrossthe course of care to “nudge” the pathway of preg-nancy, labour and birth to the normal. The model ofmidwifery care, which emphasizes continuity of care,is a vital foundation for this.Additional fileAdditional file 1: Semi-structured interview guide. (PDF 1329 kb)AbbreviationsBC: British Columbia; CS: Caesarean sectionAcknowledgementsThe author would like to thank the midwives who participated in this studyand to acknowledge the important insights that they provided.FundingThis study was funded using research start up funds provided by theuniversity. The funder had no role in design or conduct of the study, dataanalysis, interpretation of the data, or writing the manuscript.Availability of data and materialsTo protect the identity of the participants, the data generated in this studycannot be shared beyond the data extracts provided in this manuscript.Author contributionsThe author [MB] was responsible for all aspects of the study includingfieldwork, analysis and authoring the manuscript.Competing interestsThe author has no competing interests.Consent for publicationParticipants gave permission for the findings to be published in anonymousformat.Ethics approval and consent to participateThis study was approved by the Behavioural Research Ethics Committee atthe University of British Columbia (H15-00291). Participants were providedwith verbal and written information about the study before agreeing toparticipate and provided written consent before commencing face-to-faceinterviews and recorded verbal consent to participate before commencingSkype or telephone interviews.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Received: 24 November 2016 Accepted: 8 May 2017References1. SOGC. Joint policy statement on normal childbirth. JOGC. 2008;30(12):1163–5.2. Hendrix E. Routine interventions during normal labor and birth … are theyreally necessary? In: Donna S, editor. Promoting Normal Birth: research,reflections and guidelines. La Vergne: Fresh Heart Publishing; 2011. p. 6–20.3. Betrán AP, Ye J, Moller A-B, Zhang J, Gülmezoglu AM, Torloni MR. Theincreasing trend in Caesarean section rates: global, regional and nationalestimates: 1990-2014. PLoS One. 2016;11(2):e0148343–12.4. 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A hermeneutic analysis ofwomen’s negative birth experiences. Sex Reprod Healthc. 2014;5(4):199–204.40. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for womenduring childbirth. Cochrane Database Syst Rev. 2012;10:CD003766.41. Kennedy HP, Shannon MT. Keeping birth normal: research findings onmidwifery care during childbirth. JOGNN. 2004;33(5):554–60.42. Seale C. The Quality of Qualitative Research. London: Sage Publications; 1999.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Butler BMC Pregnancy and Childbirth  (2017) 17:168 Page 12 of 12

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