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The influence of environments on fear of childbirth during women’s intrapartum hospital stays Auxier, Jennifer 2017

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    THE  INFLUENCE  OF  ENVIRONMENTS  ON  FEAR  OF  CHILDBIRTH  DURING  WOMEN’S  INTRAPARTUM  HOSPITAL  STAYS    by Jennifer  Auxier      A  THESIS  SUBMITTED  IN  PARTIAL  FULFILMENT  OF   THE  REQUIREMENTS  FOR  THE  DEGREE  OF    MASTER  OF  SCIENCE  IN  NURSING  in  The  Faculty  of  Graduate  and  Postdoctoral  Studies  THE  UNIVERSITY  OF  BRITISH  COLUMBIA (Vancouver)   July,  2017 © Jennifer  Auxier,  2017   ii Abstract     Differences  in  birthing  environments  and  models  of  maternity  care  are  contributing  factors  to  women’s  fear  of  childbirth.  British  Columbia  has  higher  rates  of  caesarean  sections  than  the  Canadian  national  average  and  provides  women  with  a  variety  of  maternity  care  models  in  hospitals.  Studying  British  Columbian  women’s  perspectives  can  increase  our  understanding  of  the  influence  of  unique  hospital  birthing  environments  on  women’s  childbirth  fear.  The  study  aimed  to  investigate  women’s  perceptions  of  effects  of  hospital  birth  environments  on  their  childbirth  fear,  following  hospital-­based  labours  and  births.  The  study  design  was  qualitative  description.  Over  a  five-­month  period,  15  women  were  interviewed  individually.  Inductive  content  analysis  produced  one  major  theme:  Women’s  engagement  with  their  labours  and  births;;  the  major  theme  incorporated  six  sub-­themes:  Women’s  connection  to  their  bodies;;  women’s  inclusion  in  decision-­making  processes;;  freedom  to  use  the  hospital  space;;  feelings  of  trust  toward  professional  caregivers;;  distractions  from  labour;;  and  personalized  care.  Study  participants  linked  being  disengaged  during  their  labours  and  births  to  feelings  of  uncertainty,  fear  of  the  unknown,  and  losing  control  while  labouring  and  birthing  in  hospitals.  The  study  findings  point  to  the  importance  of  professional  caregivers  incorporating  women-­centered  care  practices  in  maternity  care.  More  investigation  into  barriers  preventing  professional  caregivers  in  British  Columbia  from  enacting  women-­centered  care  is  warranted.           iii Lay  Summary    Childbirth  fear  is  a  common  experience  for  women  who  mostly  labour  and  birth  in  hospitals.  Women’s  childbirth  fear  has  been  linked  to  more  interventionist  birth  outcomes  (e.g.  instrumental  and  surgical  assisted  births).  The  investigator  interviewed  fifteen  women  who  shared  their  experiences  of  labouring  and  birthing  in  hospital  and  the  impact  of  these  environments  on  their  childbirth  fear.  Study  participants  described  being  disengaged  from  their  labour  and  birth  experiences  in  hospital  when  they  felt  uncertainty,  fear  of  the  unknown  and  feelings  of  losing  control.  They  indicated  that  childbirth  fear  made  it  difficult  to  stay  connected  to  their  bodies  and  their  fear  was  enhanced  by  their  lack  of  inclusion  in  decision-­making  processes,  freedom  to  use  the  hospital  space,  feelings  of  trust  toward  professional  caregivers,  ability  to  focus  on  labour,  and  personalized  care.  The  study  results  underline  care  providers’  responsibilities  to  attend  to  women’s  needs  for  control  and  trust  in  the  childbirth  process.                    iv Preface     This  thesis  represented  a  collaboration  between  myself  and  my  supervisory  committee.  I  completed  the  work  of  data  collection,  and  data  analysis  with  input  from  my  primary  supervisor.  The  writing  of  the  thesis  was  completed  with  the  guidance  and  input  from  all  committee  members  including  Dr.  Wendy  A.  Hall,  Dr.  Jennifer  Baumbusch,  and  Lily  Lee.       This  thesis  project  received  ethics  approval  from  the  Human  Ethics  Board  of  UBC  Research  Ethics.  The  certificate  number  of  this  approval  is  H15-­03097.             v Table  of  Contents   Abstract ........................................................................................................................... ii Lay Summary ................................................................................................................. iii Preface ........................................................................................................................... iv Table of Contents ........................................................................................................... v List of Tables ................................................................................................................ vii Acknowledgements ..................................................................................................... viii Dedication ...................................................................................................................... ix 1: Introduction ................................................................................................................ 1 1.1 Fear of Childbirth .............................................................................................................. 1 1.2 Significance of the Study ................................................................................................. 6 1.3 Problem Statement and Purpose .................................................................................... 8 1.4 Summary ........................................................................................................................... 9 2: Literature Review ..................................................................................................... 10 2.1 Introduction ..................................................................................................................... 10 2.2 Search Methods .............................................................................................................. 10 2.3 Elements of Childbirth Fear ........................................................................................... 11 2.4 Birth Environments Affecting Childbirth Fear ............................................................. 12 2.4 Effects of Media and Personal Birth Depictions on Childbirth Fear .......................... 13 2.5 Women’s Feelings Associated with Labour and Birth ................................................ 14 2.6 Women’s Sense of Agency in Birth Environments ..................................................... 17 2.7 Summary ......................................................................................................................... 20 3: Methods ..................................................................................................................... 21 3.1 Introduction ..................................................................................................................... 21 3.2 Study Design ................................................................................................................... 21 3.3 Ethics ............................................................................................................................... 21 3.4 Inclusion and Exclusion Criteria and Recruitment ..................................................... 22 3.5 Sample Selection ............................................................................................................ 23 3.6 Data Collection ............................................................................................................... 24 3.8 Rigor ................................................................................................................................ 27 3.9 Dissemination ................................................................................................................. 29 3.10 Summary ....................................................................................................................... 29 4: Findings .................................................................................................................... 30 4.1 Introduction ..................................................................................................................... 30 4.2 Sample Characteristics .................................................................................................. 30 4.3 Women’s Engagement with Their Labours and Births ............................................... 31 4.3.1 Women’s Connections to Their Bodies ..................................................................... 37 4.3.2 Women’s Inclusion in Decision-making Processes ................................................... 42 4.3.3 Freedom to use the Hospital Space .......................................................................... 45 4.3.4 Feelings of Trust Toward Professional Caregivers .................................................... 48   vi 4.3.5 Distractions from Labour ........................................................................................... 54 4.3.6 Personalized Care ..................................................................................................... 58 4.4 Summary ......................................................................................................................... 63 5: Discussion of Findings, and Implications ............................................................. 65 5.1 Introduction ..................................................................................................................... 65 5.2 Summary of Study .......................................................................................................... 65 5.3 Discussion ...................................................................................................................... 66 5.4 Implications for Clinical Practice .................................................................................. 72 5.4.1 Women’s Engagement with Their Labours and Births .............................................. 72 5.4.2 Women’s Connection to Their Bodies ....................................................................... 73 5.4.3 Women’s Inclusion in Decision-Making ..................................................................... 73 5.4.4 Women’s Freedom to use the Hospital Space .......................................................... 74 5.4.5 Women’s Trust Toward Professional Caregivers ...................................................... 75 5.4.6 Distractions from Women’s Labours and Births ........................................................ 75 5.4.7 Personalized Care ..................................................................................................... 76 5.5 Implications for Education ............................................................................................ 77 5.4 Implications for Research .............................................................................................. 79 5.5 Strengths of the Study ................................................................................................... 80 5.6 Limitations of Study ....................................................................................................... 80 5.7 Conclusion ...................................................................................................................... 81 References .................................................................................................................... 82 Appendix A: Recruitment Letter ................................................................................. 94 Appendix B: Consent Letter ........................................................................................ 95 Appendix C: Demographic Questionnaire ................................................................. 98 Appendix D: Interview Guide ....................................................................................... 99 Appendix E:  Modified Interview Guide .................................................................... 100 Appendix F: Second Memo Part 1 ............................................................................ 102 Appendix G: Second Memo Part 2 ............................................................................ 109 Appendix H: Reflective Note ..................................................................................... 118 Appendix I: Thank You Letter .................................................................................... 119               vii List  of  Tables    TABLE 4.1 : DEMOGRAPHIC CHARACTERISTICS OF SAMPLE ........................................................... 31        viii Acknowledgements       I  offer  my  immense  gratitude  to  faculty,  staff,  and  fellow  students  at  UBC  who  have  encouraged  and  inspired  my  work  on  this  project.  I  want  to  give  particular  thanks  to  Dr.  Wendy  Hall  who  has  supported  and  challenged  me  throughout  the  work  on  this  thesis,  without  her  commitment  to  quality  and  her  gift  of  discernment  I  would  not  have  been  able  to  accomplish  this  work.  I  also  want  to  thank  my  supportive  and  expert  committee  members  whose  patience  throughout  the  process  has  given  me  stamina  in  order  to  develop  my  scholarly  skills.    I  am  forever  grateful  for  to  my  entire  committee  for  their  expert  and  kind  contributions  to  this  project.       I  am  extremely  grateful  to  Dr.  Beverley  O’Brien,  as  well  as,  the  Midwifery  and  Nursing  programs  at  UBC  for  awarding  me  the  Strengthening  Mothers  through  Perinatal  Research  award  to  support  this  thesis  project.  The  award  has  given  participants  more  opportunity  for  their  voices  to  be  heard,  as  well  as  providing  potential  for  the  study  to  have  greater  influence  through  dissemination  of  the  results.       Special  thanks  are  owed  to  my  husband  whose  support  and  efforts  have  gone  heavily  toward  my  developing  this  project  with  success  and  quality,  both  morally  and  technically.        ix Dedication       I  wish  to  dedicate  this  work  to  the  women  whose  voices  have  not  been  considered  over  the  course  of  their  maternity  care.  I  want  to  extend  my  immense  gratitude  to  the  study  participants.  Their  commitment  to  and  enthusiasm  for  telling  their  stories  will  be  forever  an  inspiration  to  me,  moving  forward  in  my  career.       I  also  wish  to  dedicate  this  work  to  my  supervisor  and  committee,  whose  continual  hard  work  stretches  far  beyond  my  master’s  project  to  many  other  avenues  of  nursing  research,  by  informing  the  public  and  their  caregivers  to  improve  women’s  wellness  and  the  quality  of  clinical  practice.  I  only  hope  I  can  achieve  as  much  in  my  career.  This  dedication  is  directed  to  Dr.  Wendy  Hall,  Dr.  Jennifer  Baumbusch,  and  Lily  Lee.       Further,  I  want  to  dedicate  this  work  to  my  husband.  Ben  Auxier  gave  his  time  and  energies  in  supporting  me  through  this  process.  His  support  and  excitement  for  my  work  continues  to  give  me  motivation.  From  his  unique  support  I  have  a  positive  anticipation  for  what  research  can  achieve  for  the  wellness  and  safety  of  women  being  served  by  health  care  systems  in  British  Columbia  and  around  the  world.        1 1:  Introduction  1.1  Fear  of  Childbirth     Fear  of  childbirth  has  been  described  as  an  extreme  fear  of  birth,  a  clinical  condition  known  as  tokophobia  (Stoll  &  Hall,  2013a).  The  prevalence  of  pregnant  women’s  fear  of  childbirth  (FOC)  in  developed  countries  is  estimated  at  20%  (Hall,  Hauck,  Carty,  Hutton,  Fenwick,  &  Stoll,  2009;;  Saisto  &  Halmesmäki,  2003).  There  is  a  range  in  the  prevalence  depending  on  the  specific  country,  suggesting  that  birth  environments  may  be  a  contributing  factor  to  women’s  perceptions  of  FOC  (Hall  et  al.,  2009).  FOC's  nature,  meanings,  prevalence,  risk  factors,  and  associated  outcomes  have  been  studied  internationally  and  in  Canada.  FOC  has  been  associated  with  poor  maternal  outcomes,  such  as  increased  rates  of  emergency  caesarean  sections  (Laursen,  Johansen,  &  Hedegaard,  2009)  and  poor  neonatal  outcomes,  e.g.  low  Apgar  scores  (Räisänen  et  al.,  2014).       The  influence  of  hospital  birthing  environments  on  FOC  in  labouring  women  has  received  limited  attention.  Differences  in  birthing  environments  and  models  of  care  internationally  appear  to  result  in  varying  manifestations  of  FOC  and  outcomes  for  labouring  women  (Cumberland,  2010;;  Nyman,  Downe,  &  Berg,  2011;;  Taghizadeh,  Arbabi,  Kazemnejad,  Irajpour,  &  Lopez,  2015).  The  variation  across  countries  suggests  that  it  is  important  to  examine  the  influence  of  birth  environments  on  women's  perceptions  of  FOC.  In  this  chapter,  I  will  describe  some  aspects  of  FOC,  explain  the  significance  of  studying  this  phenomenon  in  relation  to  hospital  birth  environments,  and  articulate  the  purpose  of  my  study.      2    Pregnant  women’s  FOC  in  late  pregnancy  can  persist  to  the  time  of  admission  to  labour  wards,  and  to  the  birth  of  the  infant  and  beyond;;  this  is  called  the  vicious  circle  of  fear  (Kjærgaard,  Wijma,  Dykes,  &  Alehagen,  2008).  There  is  evidence  that  when  FOC  is  present  during  labour  and  birth  a  physiological  cascade  of  fear  is  initiated  (Stenglin  &  Foureur,  2013).  Stenglin  and  Foureur  (2013)  outlined  the  phenomenon  of  the  fear  cascade,  which  occurs  when  epinephrine  is  released  during  a  fight  or  flight  response.  The  release  of  epinephrine  affects  oxytocin  uptake  during  labour  leading  to  a  slowing  of  labour  progress  and  vasoconstriction  throughout  the  body  (Stenglin  &  Foureur,  2013).  Vasoconstriction  has  been  linked  to  ineffective  perfusion  of  the  placenta,  prolonged  labours,  and  fetal  distress,  which  can  lead  to  instrumental  deliveries  and  emergency  caesarean  sections  (Stenglin  &  Foureur,  2013).  In  cases  in  which  this  fear  cascade  becomes  initialized,  women’s  pre-­existing  fears  about  labour  and  birth  can  be  enhanced  if  women  experience  persistent  fear-­inducing  stimuli  in  the  birth  environment  (Zar,  Wijma,  &  Wijma,  2001).       Labouring  women  are  particularly  influenced  by  hospital  birth  environments  that  are  dominated  by  the  medical  model  and  interventionist  approaches  to  birth  (Cumberland,  2010).  The  medical  model,  also  termed  the  medical  illness  model,  is  an  approach  that  portrays  birth  as  risky  and  potentially  dangerous  (McCool  &  Simeone,  2002).  The  medical  model  approaches  to  birth  utilize  surveillance  technologies,  e.g.  continuous  electronic  fetal  monitoring,  and  interventions,  e.g.  oxytocin  to  control  the  progress  of  labour  and  birth  (McCool  &  Simeone,  2002).  These  approaches  to  maternity  care  highlight  the  risks  involved  with  labour  and  birth  and  influence  labouring  women’s  perceptions  of  their  births,  often  giving  them  the  sense  that  they  can  express  limited    3 agency  in  the  context  of  their  births  (Christiaens,  Van  De  Velde,  &  Bracke,  2011;;Cumberland,  2010).     Hospital  birthing  environments  have  been  viewed  as  contributing  to  the  vicious  circle  of  fear  (Kjærgaard  et  al.,  2008).  For  example,  women’s  heightened  awareness  of  the  increased  caesarean  section  delivery  rates  in  the  United  Kingdom  has  contributed  to  the  increase  of  FOC  in  women  there  (Cumberland,  2010).  As  well,  a  study  describing  women’s  birth  practices  and  preferences  in  the  United  States  suggested  that  variation  in  women’s  attitudes  and  beliefs  about  modes  of  birth  could  derive  from  different  sources  of  fear  for  each  woman  depending  on  her  attitudes  toward  medical  models  of  birth  (Miller  &  Shriver,  2012).  The  variation  in  women’s  attitudes  toward  medical  models  of  birth  and  the  fact  that  some  women  are  fearful  of  operative  births  suggest  that  predicting  whether  different  hospital  birth  environments  will  influence  labouring  women’s  FOC  positively  or  negatively  is  complex  but  important.     We  know  that  some  women  who  have  high  levels  of  FOC  describe  birth  as  “[losing]  oneself  as  a  woman  into  loneliness”  (Nilsson  &  Lundgren,  2009,  p.  e4)  “feeling  invisible  and  out  of  control”  (Elmir,  Schmied,  Wilkes,  &  Jackson,  2010,  p.  2145)  and  “feeling  trapped”  (Elmir  et  al.,  2010,  p.  2142);;  all  of  these  feelings  can  act  as  triggers  for  entering  the  fear  cascade.  Women,  with  such  experiences,  describe  having  deeply  uncomfortable  thoughts  and  feelings  during  labour  and  birth,  resulting  in  efforts  to  find  solace  in  expediting  their  births.  In  an  Iranian  study,  70.6%  of  women  who  chose  caesarean  section  had  FOC,  whereas  only  10.9%  of  women  who  chose  vaginal  delivery  reported  FOC  (Matinnia  et  al.,  2015).  Some  women  who  have  high  levels  of  FOC  appear  to  be  choosing  to  have  higher  interventions  in  labour  and  birth  (Cumberland,    4 2010;;  Matinnia  et  al.,  2015;;  Saisto  &  Halmesmäki,  2003;;  Serçekuş  &  Okumuş,  2009;;  Stoll  &  Hall,  2013b;;  Waldenstrom,  Hildingsson,  &  Ryding,  2006);;  therefore,  understanding  how  hospital  environments  might  affect  women’s  FOC  is  an  important  avenue  for  study.       Recent  studies  have  identified  the  outcomes  resulting  from  midwifery  led  care  and  medical  models  of  care.  In  a  current  review  examining  the  two  models  of  care  it  was  found  that  similar  mortality  and  morbidity  rates  were  associated  with  the  midwifery  care  and  medical  care  models  (Sandall,  Soltani,  Gates,  Shennan,  &  Devane,  2015);;  however,  midwifery  models  of  care  were  associated  with  cost  benefits  and  more  positive  birth  experiences  (Soltani  &  Sandall,  2012).  Medical  models  of  birth  have  offered  benefits  in  terms  of  women’s  and  infants’  life  preservation  and  positive  public  health  initiatives  (McCool  &  Simeone,  2002).  Because  there  are  benefits  to  both  the  medical  and  midwifery  models  an  important  avenue  for  study  exists  in  British  Columbia  where  surgical  intervention  rates  for  birth  have  risen  (Perinatal  Services,  2011)  and  a  variety  of  care  models  are  being  utilized  in  hospital  birth  environments  (Perinatal  Services,  2016).     During  intrapartum  hospital  stays  women  often  encounter  care  providers  and  institutional  procedures  that  do  not  take  into  account  their  specific  worries  about  their  births  (Nyman  et  al.,  2011).  Nyman  and  colleagues  (2011)  stated  that  this  lack  of  attention  leads  to  asymmetry  between  labouring  women  and  hospitals  as  institutions.  Such  encounters  demonstrate  a  pattern  powered  by  professionals,  which  has  been  viewed  as  negatively  influencing  pregnant  women’s  feelings  of  self-­confidence,  self-­esteem,  and  self-­efficacy  (Nyman  et  al.,  2011).  A  system  that  is  powered  by    5 professionals  can  be  defined  as  a  patriarchal  system.  A  patriarchal  system  is  one  in  which  a  powerful  group  of  individuals,  often  adult  men,  lead  the  actions  and  practices  of  others,  perceived  as  a  less  powerful,  group  of  individuals  (Muzaffar,  2011).  In  the  case  of  medical  models  of  birthing,  patriarchal  approaches  have  historically  been  enacted  in  hospital  birth  environments  (McCool  &  Simeone,  2002).  The  landscape  of  maternity  care  is  complex  because  some  women  who  enter  hospital  environments  find  reassurance  and  a  sense  of  control  when  they  receive  medically  led  care  during  their  labours  and  births  (Haines,  Rubertsson,  Pallant,  &  Hildingsson,  2012;;  Miller  &  Shriver,  2012).  Nonetheless  a  willingness  to  surrender  control  has  been  linked  to  women  acting  as  passive  agents  in  their  births  (Luce  et  al.,  2016).       Research  situated  in  the  western  world  has  examined  women’s  perceptions  of  their  birth  environments.  Most  findings  report  women’s  level  of  satisfaction  with  their  birth  experiences;;  some  minor  themes  about  fear  during  labour  are  reported  but  none  of  the  studies  have  described  an  association  between  FOC  and  hospital  birth  environments  (Bernhard,  Zielinski,  Ackerson,  &  English,  2014;;  Johnson,  Callister,  Freeborn,  Beckstrand,  &  Huender,  2007;;  Nilsson  &  Lundgren,  2009;;  Rudman,  El-­Khouri,  &  Waldenström,  2007;;  Taghizadeh  et  al.,  2015;;  Wu  &  Chung,  2003).  Furthermore,  studies  have  not  focused  on  the  influence  of  environments  on  FOC  during  women’s  intrapartum  hospital  stays  in  Canada.       Between  2006  and  2007,  97.9%  of  Canadian  women  gave  birth  in  hospitals  and/or  clinics  (Bartholomew  &  Public  Health  Agency  of  Canada,  2009).  Canadian  hospitals  have  higher  rates  of  caesarean  sections  than  many  other  publicly  funded  healthcare  systems  in  the  world,  such  as  the  Netherlands,  Finland,  and  Norway  (Soltani  &  Sandall,    6 2012).  Canadian  rates  are  closer  to  those  of  the  United  States,  a  country  that  predominately  runs  a  for-­profit  healthcare  system  (Soltani  &  Sandall,  2012).  British  Columbia’s  caesarean  section  rate  is  13%  higher  than  the  Canadian  national  average  and  has  been  trending  upwards  (Perinatal  Services  BC,  2011).  These  factors  underscore  the  importance  of  studying  the  influence  of  British  Columbian  hospital  birth  environments’  on  women’s  FOC.  1.2  Significance  of  the  Study     FOC  has  been  associated  with  women  choosing  elective  caesarean  sections  (Cumberland,  2010;;  Fenwick,  Toohill,  Creedy,  Smith,  &  Gamble,  2015;;  Fisher,  Hauck,  &  Fenwick,  2006;;  Haines  et  al.,  2012;;  Hildingsson,  2014;;  Ryding  et  al.,  2015;;  Stoll  et  al.,  2009;;  Storksen,  Eberhard-­Gran,  Garthus-­Niegel,  &  Eskild,  2012;;  Tsui  et  al.,  2007;;  Waldenstrom,  Hildingsson,  &  Ryding,  2006).  FOC  can  also  increase  women’s  risk  for  emergency  caesarean  sections,  instrumental  deliveries,  postpartum  depression  (PPD),  post-­traumatic  stress  disorder  (PTSD)  (Fisher  et  al.,  2006;;  Sluijs,  Cleiren,  Scherjon,  &  Wijma,  2012),  and  feelings  of  poor  connectedness  to  their  newborns  (Fisher  et  al.,  2006).       In  a  Perinatal  Services  BC  Surveillance  Special  Report  (2011)  the  rate  of  caesarean  delivery  in  British  Columbia  was  reported  to  be  “one  of  the  highest  in  Canada,  and  has  [been]  increasing  steadily  and  significantly  over  the  last  decade  from  27.1%  in  2001/2002  to  31.0%  in  2010/2011”  (Perinatal  Services  BC,  2011).  Furthermore,  the  rate  of  caesarean  sections  in  BC  was  13%  higher  than  the  national  average  in  2009/2010  (Perinatal  Services  BC,  2011).  The  rise  in  caesarean  sections  in  British  Columbia  increases  risks  of  complications  for  mothers  and  infants  as  well  as  cost    7 to  the  public  and  the  use  of  resources  (Perinatal  Services  BC,  2011).  Because  FOC  appears  to  be  a  contributing  factor  to  elective  and  emergency  caesarean  sections  and  the  proportion  of  women  experiencing  caesarean  births  in  British  Columbia  continues  to  rise,  potential  contributions  of  British  Columbian  hospital  environments  to  this  phenomenon  require  investigation.  Exploring  women’s  perceptions  of  hospital  environments  in  relation  to  their  FOC  will  inform  healthcare  providers  about  women’s  experiences  of  FOC  in  those  settings.     Birthing  environments  and  women’s  subjective  experiences  of  birth  are  affected  by  the  models  of  care  being  provided,  whether  interventionist  or  low  intervention.  Women’s  personalities,  life  experience,  awareness  of  birth  practices  and  birthing  options  available  to  them  in  their  communities,  and  their  potential  interactions  with  particular  models  of  care  all  contribute  to  their  specific  attitudes  and  beliefs  about  maternity  models  of  care  (Haines,  et  al.,  2012).  Therefore,  women’s  subjective  experiences  provide  important  information.  If  women  have  poor  experiences  in  their  birth  environments,  poor  outcomes  can  result  (Simkin,  1991).  When  women  perceive  their  birth  experiences  as  negative  they  have  been  more  likely  to  report  PTSD  (Ayers,  2014).  A  common  theme  in  the  literature  situated  in  Western  countries  is  that  maternity  care  services  should  respond  to  women’s  desires  about  birth  practices  and  care  to  prevent  negative  outcomes,  such  as  PTSD  and  FOC  (Ayers,  2014).       Researchers  exploring  causes  of  FOC  have  suggested  that  maternity  care  systems  could  be  contributing  to  the  problem  (Eriksson,  Westman,  &  Hamberg,  2006).  Effects  of  hospital  environments  on  FOC  have  not  been  examined  extensively  in  the  literature;;  however,  seminal  work  has  emphasized  the  importance  of  preventing  poor    8 birth  and  labour  experiences  for  women,  which  contribute  to  women's  negative  psychological  status  post  birth  (Simkin,  1991).  Because  poor  labour  and  birth  experiences  can  negatively  influence  mothers’  abilities  to  preserve  family  wellness,  resulting  in  ill  effects  for  society  (Simkin,  1991),  it  is  important  to  understand  the  influence  hospital  birth  environments  have  on  women’s  perceptions  of  FOC.       Birth  environments  around  the  world  influence  women's  perceptions  of  FOC  differently  depending  on  each  setting  and  the  care  models  implemented.  Canadian  women’s  perceptions  of  the  influence  of  their  birth  environments  on  their  FOC  are  important.  Canada  has  a  high  rate  of  caesarean  sections  in  comparison  to  other  publicly-­funded  healthcare  systems  in  the  world,  such  as  in  the  Netherlands,  Finland,  and  Norway  (Soltani  &  Sandall,  2012).  Using  British  Columbia  as  the  study  setting  provides  access  to  different  models  of  care  being  practiced  within  hospital  birth  environments,  e.g.  medical  models  and  midwifery  models  of  care  (Perinatal  Services  BC,  2016),  which  could  have  implications  for  women’s  FOC.    1.3  Problem  Statement  and  Purpose     A  significant  proportion  of  Canadian  women  (about  one-­quarter)  report  FOC  (Hall  et  al.,  2009).    Having  FOC  has  been  associated  with  a  preference  for  caesarean  section  as  a  birth  modality  (Haines,  et  al.,  2012).  Researchers  have  estimated  that  a  significant  proportion  (20%)  of  women  in  developed  countries  report  FOC  (Saisto  &  Halmesmäki,  2003).  The  majority  of  Canadian  women  give  birth  in  hospitals  (Bartholomew  &  Public  Health  Agency  of  Canada,  2009).  Evidence  suggests  that  hospital  birth  environments  play  a  role  in  women’s  perceptions  of  FOC;;  similar  effects  are  likely  in  British  Columbia.  Studying  hospital  birth  environments  to  identify  how  or  whether  cultural  factors,  stimuli,    9 and  circumstances  influence  FOC  is  important  to  further  our  understanding  of  women’s  FOC.  Therefore,  this  study  aimed  to  explore  women’s  perceptions  of  the  effects  of  hospital  birth  environments  on  their  FOC.  My  research  question  was:  What  are  women’s  perceptions  of  the  influence  of  environments  on  FOC  during  their  intrapartum  hospital  stays?  1.4  Summary     In  this  chapter,  I  have  explained  relationships  between  women’s  FOC  and  hospital  birth  environments,  as  well  as  implicating  the  effects  of  the  medicalization  of  birth  for  women’s  birth  experiences.  I  have  provided  rationale  for  British  Columbia  being  of  particular  interest  for  the  study  because  of  the  high  caesarean  section  rate.  I  have  summarized  my  research  problem  and  presented  the  purpose  of  the  study.  In  the  next  chapter,  I  present  the  literature  on  childbirth  fear  and  women’s  perceptions  of  their  birth  experiences  and  environments  to  illustrate  the  gap  in  the  literature  that  necessitated  the  study.                   10 2:  Literature  Review  2.1  Introduction       In  this  chapter,  I  synthesize  and  critically  evaluate  the  literature  to  examine  FOC  in  the  context  of  women’s  birth  experiences  and  environments  and  gaps  in  understanding  about  hospital  birth  environments’  influence  on  FOC.  I  also  explore  potential  effects  of  FOC.  I  begin  the  chapter  with  a  description  of  my  search  methods,  followed  by  a  discussion  of  birth  environment  factors  affecting  FOC,  relationships  of  media  and  birth  depictions  with  FOC,  and  women’s  feelings  and  agency  in  birth  associated  with  FOC.  In  the  process  of  synthesizing  the  literature,  I  demonstrate  gaps  in  understanding  that  point  to  the  necessity  of  conducting  a  qualitative  descriptive  study  about  women's  perceptions  of  the  influence  of  environments  on  FOC  during  their  intrapartum  hospital  stays.  2.2  Search  Methods     My  search  method  involved  the  use  of  the  following  keywords:  Childbirth  fear,  childbirth,  birth,  parturition  (MeSH  term),  maternity,  intrapartum  care,  experiences,  and  perceptions  in  various  combinations  with  the  use  of  Boolean  terms.  I  limited  my  search  to  include  search  terms,  such  as  questionnaire,  program  evaluation,  and  interview  and  I  accepted  qualitative  and  quantitative  studies.  I  included  only  literature  pertaining  to  healthy  childbearing  women’s  perceptions  of  their  birth  experiences  in  their  birth  environments.  I  completed  searches  in  the  CINAHL  and  PubMed  databases.  My  search  activities  yielded  54  studies.  The  total  number  of  articles  used  for  this  literature  review  was  28  after  using  my  exclusion  criteria.    11 I  excluded  all  peer-­reviewed  articles  that  referenced  treatments  and  interventions  for  childbirth  fear  and  fathers’  FOC.  I  also  excluded  studies  focusing  on:  Education  techniques  for  professional  caregivers  and  women  about  FOC;;  how  FOC  is  understood  in  subgroups  of  women  (i.e.  lesbian  women,  women  with  high-­risk  pregnancies,  and  immigrant  women);;  women’s  experiences  of  high-­risk  pregnancies  or  birth  complications;;  and  midwives'  or  nurses’  perceptions  of  childbirth  environments.  I  also  excluded  studies  that  were  not  published  in  English.    2.3  Elements  of  Childbirth  Fear     The  most  widely  used  measure  of  childbirth  fear  is  the  Wijma  Delivery  Expectancy/Experience  Questionnaire  (W-­DEQ)  (Wijma,  Wijma,  &  Zar,  1998).  The  W-­DEQ  incorporates  items  capturing  women’s  perceptions  about  past  births  or  thoughts  about  possible  future  births  in  the  form  of  expectations  and  subjective  experiences  (Wijma,  Wijma,  &  Zar,  1998).  A  psychometric  analysis  of  this  tool  was  performed  and  several  sub-­factors  of  FOC  were  identified  (Garthus-­Niegel,  Størksen,  Torgersen,  Von  Soest,  &  Eberhard-­Gran,  2011).  These  sub-­factors  included:  Loneliness,  lack  of  self-­efficacy,  lack  of  positive  anticipation,  and  concern  for  a  child’s  welfare  (Garthus-­Niegel,  Størksen,  Torgersen,  Von  Soest,  &  Eberhard-­Gran,  2011).       In  a  four-­factor  measure  of  FOC  developed  from  Lowe’s  (2000)  Childbirth  Attitudes  Questionnaire  (CAQ)  Christiaens  and  colleagues  (2011)  framed  FOC  in  a  number  of  ways  including  women’s  perceptions  of  hospital  birth  environments.  The  factors  included:  “(1)  Fear  about  the  baby’s  well-­being,  (2)  fear  of  labour  pain  and  injuries,  (3)  personal  control-­related  fear,  and  (4)  fear  of  medical  interventions  and  hospital  care”  (p.222).  Christiaens  and  colleagues  (2011)  demonstrated  the  validity  of  their  shortened    12 version  of  the  Childbirth  Attitudes  Questionnaire  by  identifying  that  “its  averaged  total  scores  were  significantly  correlated  (r  =  0.55;;  p  <  0.001)  with  the  averaged  total  scores  of  the  antenatal  version  of  W-­DEQ”  (p.225).  Although  factors  from  these  two  measures  of  FOC  have  some  overlap,  the  measures  do  not  entirely  account  for  experiences  women  have  reported  in  circumstances  where  they  are  exposed  to  medical  models  (emphasis  on  risk  and  management  of  risk)  of  maternity  care.  The  W-­DEQ  continues  to  measure  women’s  levels  of  FOC  around  the  world  (Pallant  et  al.,  2016).  Nonetheless,  Christiaens'  and  colleagues’  work  suggested  a  link  between  hospital  environments  and  FOC.  2.4  Birth  Environments  Affecting  Childbirth  Fear       My  synthesis  of  the  literature  about  fear  related  to  hospital  birth  environments  revealed  that  women’s  subjective  experiences  about  their  labour  and  birth  environments  are  situated  in  contexts  that  influence  their  perceptions  of  fear.  For  example,  low-­risk  Chinese  women  described  their  fears  about  the  childbirth  process,  problems  with  healthcare  providers,  and  lack  of  control  (Tsui  et  al.,  2007).  Furthermore,  an  English  researcher  identified  common  elements  associated  with  women’s  FOC  including:  The  possibility  of  complications  from  birth,  experiencing  pain,  having  an  emergent  caesarean  birth  or  interventions  imposed  on  them,  and  encountering  unequal  power  relations  between  themselves  and  healthcare  professionals  (Cumberland,  2010).  Similarly,  Iranian  women  described  giving  birth  in  highly  medicalized  hospital  maternity  services  where  they  had  psychological  trauma  associated  with  feelings  of  loneliness  and  less  psychological  support  and  alleviation  of  pain  than  they  had  expected  (Taghizadeh  et  al.,  2015).  In  Canada,  where  physicians  continue  to  manage  the    13 majority  of  births,  women’s  fears  about  medical  management,  imposed  interventions,  and  lack  of  control  may  be  realized.  Thus,  it  is  important  to  explore  Canadian  women’s  perceptions  of  the  influence  of  hospital  environments  on  their  childbirth  fear.    2.4  Effects  of  Media  and  Personal  Birth  Depictions  on  Childbirth  Fear  Women,  even  prior  to  pregnancy,  are  exposed  to  media  images  and  stories  from  family  and  friends  that  affect  their  beliefs  and  attitudes  about  birth  in  ways  that  can  diminish  or  enhance  FOC  (Stoll  &  Hall,  2013a).  North  American  studies  suggest  that  non-­pregnant  women  who  have  high  levels  of  FOC  generated  from  media  depictions  of  hospital  birth  often  prefer  elective  caesarean  section  as  a  mode  of  delivery  (Stoll,  Edmonds,  &  Hall,  2015).  Negative  media  depictions  of  birth  can  portray  elements  of  the  environments  of  hospital  birthing  areas  that  emphasize  women’s  helplessness  and  need  for  interventions,  thereby,  acting  as  contributing  factors  to  some  women  developing  FOC  (Morris  &  McInerney,  2010;;  Serçekuş,  &  Okumuş,  2009).    Women  anticipating  childbearing  have  also  reported  that  their  FOC  was  influenced  by  stories  they  had  heard  from  family  members  or  peers,  particularly  those  portraying  labour  and  birth  as  dramatic  and  risky  (Fenwick  et  al.,  2015;;  Stoll  &  Hall,  2013b;;  Tsui  et  al.,  2007).  Women  who  are  pregnant  for  the  first  time  and  exposed  to  dramatic  and  perilous  depictions  of  birth  through  family  members  or  the  media  appear  to  worry  about  birthing  (Fenwick  et  al.,  2015;;  Morris  &  McInerney,  2010).  Depictions  of  birth  portrayed  by  media  present  emergent  and  dramatic  situations  requiring  intervention  by  healthcare  providers  as  the  norm  (Stoll  &  Hall,  2013b).  Such  depictions  can  suggest  to  women  that  their  own  birth  experiences  could  include  some  of  these  emergent  and  dramatic  situations  requiring  pharmacological  and  medical    14 interventions  (Stoll  &  Hall,  2013b).  Birth  constructions  from  media  depictions  of  birth  likely  influence  labouring  women’s  perceptions  of  their  encounters  with  hospital  environments.    If  women  have  constructed  emergent  and  dramatic  births  as  the  norm  in  hospitals,  they  may  experience  the  initiation  of  the  fear  cascade  when  they  enter  hospital  birth  environments.  Initiation  of  the  fear  cascade  is  said  to  occur  when  women  feel  that  their  worst  fears  are  being  realized;;  the  stress  response  is  proposed  to  affect  both  mother  and  fetus  by  prolonging  labour  and  causing  vasoconstriction  in  the  mother’s  circulatory  system  which  impacts  placental  profusion,  known  as  the  fear  cascade  (Stenglin  &  Foureur,  2013;;  Zar,  Wijma,  &  Wijma,  2001).  These  conditions  can  result  in  poor  outcomes  for  the  fetus,  such  as  low  Apgar  scores  (Räisänen  et  al.,  2014)  2.5  Women’s  Feelings  Associated  with  Labour  and  Birth     Between  5  and  20  percent  of  pregnant  women  in  the  western  world  report  FOC  (Adams  et  al.,  2012;;  Fenwick  et  al.,  2015;;  Greer  &  Dunne,  2014;;  Kjærgaard  et  al.,  2008)  with  6  to  10  percent  of  these  pregnant  women  reporting  disabling  fear  that  affects  their  daily  lives  (Kjærgaard  et  al.,  2008).  In  Australia  and  Sweden,  women  who  describe  high  levels  of  FOC  have  reported  more  negative  birth  experiences  and  higher  intensity  of  labour  pain  compared  to  women  who  describe  having  less  or  no  FOC  (Haines  et  al.,  2012).  As  well,  Kasai  and  colleagues  (2010)  suggested  that  ambivalent  feelings  about  pregnancy  and  birth  can  lead  to  pregnancy-­related  FOC.  Much  of  the  literature  that  explores  women’s  perceptions  of  their  birth  experiences  has  revealed  that  women  have  experienced  feelings  of  loss  of  control  (Tsui  et  al.,  2007),  reduced  self-­efficacy  (Nilsson  &  Lundgren,  2009),  and  loneliness  (Nilsson    15 &  Lundgren,  2009);;  all  of  those  feelings  have  been  viewed  as  important  factors  in  understanding  how  FOC  is  linked  to  hospital  environments  (Garthus-­Niegel  et  al.,  2011).  Women  have  reported  being  fearful  of  panicking  from  the  experiences  of  pain  during  their  labours  (Melender,  2006)  and  interventions  that  they  expected  hospital  caregivers  to  enact  (Christiaens  et  al.,  2011;;  Miller  &  Shriver,  2012),  as  well  as    effects  of    “fear-­based”  (Bernhard  et  al.,  2014,  p.162)  perspectives  of  the  professional  caregivers  on  their  labour  experiences.  Healthcare  professionals  have  often  provided  care  using  a  medical  model  that  emphasizes  risks  of  birth  rather  than  focusing  on  some  of  the  natural  and  normal  components  of  the  birth  process  (Cumberland,  2010).  These  environments  have  the  potential  to  evoke  feelings  of  loss  of  control  (Tsui  et  al.,  2007)  Depending  on  pregnant  women’s  attitudes  toward  labour  practices  and  management,  birth  environments  can  affect  their  perceptions  of  FOC.  There  is  a  significant  proportion  of  women  who  believe  that  the  pain  of  labour  is  not  something  to  be  afraid  of  at  all  (Johnson  et  al.,  2007),  and  that  they  are  safe  when  experiencing  the  natural  course  of  labour  and  feeling  labour  pain.  Women  in  the  Netherlands  who  delivered  at  home  have  described  the  environment  as  contributing  to  their  ability  to  have  agency  over  environmental  factors  associated  with  birth  (Johnson  et  al.,  2007).  Units  in  hospitals  that  are  devoted  to  labour  and  birth  are  often    environments  that  encourage  relatively  rapid  completion  of  labour  and  eradication  of  pain  (Christiaens  et  al.,  2011;;  Janssen  et  al.,  2002).  Conflicts  between  women’s  and  healthcare  providers’  approaches  to  birth  may  exist,  which  can  create  stress  for  the  labouring  women  (Janssen  et  al.,  2002;;  Johnson  et  al.,  2007).  Although  hospital  birth  environments  utilize  medical  models  of  birthing,  there  is  variation  in  the  healthcare  providers  that  attend    16 births  in  hospitals;;  the  physiologically-­driven  model  of  care  is  sometimes  utilized  in  hospital  birth  environments,  for  example  when  registered  midwives  attend  women  and  manage  their  births  in  hospitals  (Perinatal  Service  BC,  2016).  Because  of  the  different  models  of  care  utilized  in  hospitals,  there  is  likely  variation  in  the  experiences  of  women  who  are  birthing  in  hospital  environments  both  within  their  own  countries  and  around  the  world.      The  literature  reveals  that  some  women  have  described  experiences  of  personal  agency  during  their  births.  For  example,  women  have  described  feelings  of  empowerment  and  pleasure  in  their  freedom  to  choose  where  and  when  they  carried  out  labour  activities,  i.e.,  moving,  bathing,  sleeping,  and  eating  (Bernhard  et  al.,  2014;;  Johnson  et  al.,  2007;;  Melender,  2006).  Findings  from  an  American  study  investigating  women's  childbirth  preferences  and  practices  revealed  a  consistent  theme  of  the  need  for  agency  during  intrapartum  care  (Miller  &  Shriver,  2012).  According  to  Miller  and  Shriver  (2012)  all  women  in  their  study  would  be  acting  with  agency  if  their  labour  and  birth  experiences  matched  their  expectations.  They  suggested  that  women  who  felt  agentic  during  their  labours  and  births  appeared  to  feel  a  sense  of  accomplishment  after  giving  birth  in  whatever  setting.    When  women  in  Western  Sweden  and  their  partners  were  asked  about  their  first  impressions  upon  entering  hospital  labour  wards  one  woman  described  going  to  the  labour  ward  for  the  first  time  as  scary  because  she  did  not  know  what  to  expect  (Nyman  et  al.,  2011).  In  Iran  pregnant  women  felt  afraid  when  they  saw  hospital  instruments  during  the  course  of  their  labours  (Taghizadeh  et  al.,  2015).  Taghizadeh  and  colleagues  (2015)  also  found  that  “all  mothers  in  [their]  study  experienced  fear  in  connection  with    17 the  physical  structure  of  the  delivery  or  operation  rooms  as  they  perceived  these  rooms  as  similar  to  mortuaries  for  dead  people”  (p.6).  Although  Iranian  women’s  perceptions  about  mortuaries  are  rather  unique,  it  is  clear  that  their  impressions  of  their  birth  environments  negatively  affected  their  birth  experiences.  One  of  the  Iranian  participants  also  suggested  that  healthcare  providers  did  not  seem  to  place  importance  on  the  fear  she  had  about  her  labour  and  delivery  (Taghizadeh  et  al.,  2015).  The  findings  from  this  study  are  helpful  for  demonstrating  links  between  birth  environments  and  women’s  subjective  experiences  of  childbirth  fear;;  however,  they  have  limited  generalizability  because  the  researchers  were  investigating  the  perceptions  of  women  who  had  experienced  psychological  birth  trauma  in  Iran  (Taghizadeh  et  al.,  2015).    2.6  Women’s  Sense  of  Agency  in  Birth  Environments     Women’s  perceptions  of  their  capacity  for  personal  agency  during  their  labours  and  births  has  been  a  theme  in  the  literature  describing  women’s  fears  about  childbirth  and  their  perceptions  of  their  birth  environments  (Fisher  et  al.,  2006;;  Nyman  et  al.,  2011;;  Taghizadeh  et  al.,  2015).  Pregnant  women’s  reasons  for  having  little  to  no  capacity  for  agency  during  their  labours  and  births  include:  Having  limited  information  and  knowledge  about  their  births  and  labours  (Fisher  et  al.,  2006);;  receiving  impersonal  care  from  professional  caregivers  (Taghizadeh  et  al.,  2015);;  and  being  socially  placed  in  an  inferior  position  in  birthing  environments,  in  particular,  labour  wards  in  hospitals  (Nyman  et  al.,  2011).  Some  women  have  been  described  in  the  literature  as  becoming  so  dissatisfied  with  their  limited  capacity  for  agency  while  in  hospital  birth  environments  that  they  chose  a  home  birth  for  their  next  pregnancies  because  they  felt  these  spaces    18 gave  them  more  control  over  their  labours  and  births  (Bernhard  et  al.,  2014;;  Johnson  et  al.,  2007).       Fisher  and  colleagues  (2006)  explored  birth  environments  affecting  childbirth  fear  in  contexts  using  medical  models  of  maternity  care.  They  argued  that,  because  most  women  have  no  authoritative  knowledge  about  childbirth,  they  give  control  of  their  birthing  experiences  to  care  providers  thereby  putting  social  control  over  childbirth  in  the  hands  of  the  healthcare  professionals  (Fisher  et  al.,  2006).  This  can  sometimes  be  due  to  their  feelings  of  inadequacy,  which  are  associated  with  their  heightened  fear  of  birth  (Fisher  et  al.,  2006).     Nyman  and  colleagues  (2011)  described  how  Swedish  women  perceived  their  level  of  agency  over  their  birth  environments  in  a  study  about  women’s  first  impressions  of  entering  labour  wards.  Women  in  this  study  described  feelings  of  being  placed  in  inferior  positions  to  the  healthcare  providers  because  they  were  made  to  wait  for  information  for  unspecified  amounts  of  time  (Nyman  et  al.,  2011).  Iranian  women,  in  Taghizadeh's  and  colleagues'  (2015)  study,  expressed  frustration  and  disappointment  with  the  maternity  services  they  received,  specifically  due  to  the  rules  for  the  restriction  of  women’s  activities  while  in  labour  and  limitations  imposed  on  individuals  wanting  to  support  mothers.  In  that  study,  no  support  person  was  allowed  to  accompany  the  mothers  during  labour  and  that  lack  of  support  contributed  to  the  women’s  fears  (Taghizadeh  et  al.,  2015).       Some  women  have  chosen  home  birth  after  having  hospital  births;;  their  reasons  included:  Avoiding  experiences  of  personal  dismissal  by  medical  professionals;;  being  given  perceived  choices  but  no  real  freedom  to  choose;;  being  interrupted  by  many    19 healthcare  providers;;  and  being  subjected  to  unwanted  interventions  (Bernhard  et  al.,  2014).  Bernhard  and  colleagues  (2014)  also  found  that  women  who  chose  home  birth,  after  having  experienced  a  hospital  birth,  expected  to  be  “taking  back  control  of  their  bodies  and  births”  (p.162).  The  authors  of  this  study  argued  that  women  who  maintained  control  over  their  processes  had  affirming  birth  experiences  regardless  of  the  location  of  their  births  (Bernhard  et  al.,  2014).       Women  who  have  given  birth  in  their  home  environments  by  choice  have  reported  feelings  of  control  during  labour  and  birth  (Johnson  et  al.,  2007).  In  a  study  exploring  decision-­making  and  preferences  of  women  who  had  experienced  both  hospital  and  home  births,  the  women  who  gave  birth  at  home  described  experiencing  more  control  of  birth  and  themselves  (Bernhard  et  al.,  2014).  Complex  factors  in  hospital  environments  appear  to  have  contributed  to  women's  beliefs  that  they  had  little  control  over  what  happened  during  their  labours  and  births  (Taghizadeh  et  al.,  2015).  In  a  study  about  Iranian  women’s  perceptions  of  their  birth  environments,  the  women  were  particularly  concerned  about  health  care  providers’  communication  with  them  and  rules  governing  hospital  environments;;  those  elements  seemed  to  be  enacted  in  a  way  that  emphasized  risk  management  rather  than  addressing  women’s  fears  and  unique  needs  (Taghizadeh  et  al.,  2015).  Women  have  expressed  their  desires  to  make  birth  uncomplicated,  either  through  the  bypassing  of  labour  and  receiving  a  surgical  birth  for  non-­medical  reasons  (Waldenstrom  et  al.,  2006)  or  by  avoiding  all  intervention  in  birth  because  they  view  birth  as  a  natural  process  rather  than  an  inherently  risky  one  (Johnson  et  al.,  2007).    20    Childbirth  fear  has  been  portrayed  as  prevalent  in  communities  around  the  world  (Hall  et  al.,  2009;;  Kjærgaard  et  al.,  2008).  Pregnant  women  in  a  number  of  countries  described  negative  birthing  experiences  in  hospital  environments  where  medicalized  birth  has  been  prominent,  in  part,  related  to  their  perceptions  that  these  environments  have  contributed  to  them  having  limited  capacity  for  agency  during  their  labours  and  births  (Fisher  et  al.,  2006;;  Nyman  et  al.,  2011;;  Taghizadeh  et  al.,  2015).  Canadian  women’s  births  are  generally  managed  by  physicians,  at  84.2%  (Bartholomew  &  Public  Health  Agency  of  Canada,  2009).  Physicians’  management  of  birth,  including  operative  deliveries,  affects  the  context  of  hospital  birth.  Canadian  women’s  perceptions  of  the  effects  of  hospital  environments  on  their  FOC  may  vary  from  those  of  women  in  other  countries.  It  is  possible  that  women  who  exposed  to  portrayals  in  the  North  American  media  of  birth  as  risky  and  requiring  management  by  physicians  have  differing  perspectives  about  FOC.  Therefore,  an  exploration  of  Canadian  women’s  experiences  of  the  influence  of  hospital  environments  on  their  FOC  can  contribute  to  the  literature  and  our  understanding  of  FOC.  2.7  Summary       This  chapter  has  included  a  description  of  the  search  terms  used  to  support  my  literature  review,  as  well  as  the  primary  themes  developed  from  my  synthesis  of  the  literature.  The  themes  included:  The  nature  of  childbirth  fear;;  environments  affecting  childbirth  fear;;  effects  of  media  and  others’  birth  depictions  on  childbirth  fear;;  women’s  feelings  associated  with  childbirth  fear;;  and  women’s  sense  of  agency  in  birth  environments.  In  the  next  chapter,  I  describe  my  study  design  and  methods.         21 3:  Methods 3.1  Introduction     In  this  chapter,  I  describe  my  study  methods  and  design.  I  have  included  my  procedural  activities:  Obtaining  ethical  approval,  sampling  techniques,  data  collection,  and  data  analysis,  as  well  as  plans  for  dissemination  of  my  study  findings.  I  have  described  how  the  participants’  semi-­structured  interviews  led  to  the  creation  of  probing  questions  that  further  developed  interview  topics  and  the  process  of  analysis  of  participants’  perceptions  of  their  hospital  birth  environments,  including  details  about  my  coding,  categorizing  and  clustering  of  the  raw  data.    3.2  Study  Design     I  used  a  qualitative  descriptive  study  design  to  investigate  the  influence  of  hospital  birth  environments  on  women’s  perceptions  of  FOC.  Qualitative  description  is  used  to  inquire  about  straight  descriptions  of  events,  (i.e.  what,  why,  and  who  of  events)  (Sandelowski,  2000).  My  description  of  effects  of  the  hospital  environments  on  women’s  feelings  and  events  during  labour  and  birth  is  useful  to  answer  the  research  question  because  it  captured  the  phenomena  that  were  meaningful  for  women’s  perceptions  of  their  FOC.        3.3  Ethics     I  applied  for  and  received  ethical  approval  from  the  UBC  Office  of  Research  Ethics  Behavioural  Research  Ethics  Board  (BREB).  To  adhere  to  ethical  standards,  I  incorporated  the  following  elements  in  my  study:          Participants  received  detailed  information  about  what  would  be  required  of  them  prior  to  semi-­structured  interviews.  The  recruitment  letter  (Appendix  A)  included  explicit    22 information  about  how  to  exit  the  study  at  any  time  during  the  process  if  the  participants  felt  unable  to  continue,  including  after  the  interviews  had  been  performed.  Participants  who  agreed  to  take  part  in  my  study  received  a  consent  form  (Appendix  B)  by  email,  which  allowed  them  time  to  consider  providing  informed  consent.  They  reviewed  and  signed  the  consent  form  prior  to  their  interviews.  Additionally,  I  provided  participants  with  information  about  counselling  and  support  services  by  email  after  the  interviews  had  taken  place  in  the  event  that  any  individuals  were  experiencing  negative  emotional  reactions  following  their  participation  in  the  study.   3.4  Inclusion  and  Exclusion  Criteria  and  Recruitment     My  inclusion  criteria  comprised:  (a)  Women  who  had  delivered  only  one  child  vaginally  or  by  caesarean  section  in  a  hospital  located  in  the  lower  mainland  of  British  Columbia;;  (b)  women  who  had  delivered  at  least  two  months  prior  to  the  study;;  and  (c)  women  who  spoke  English  fluently.  The  rationale  for  including  women  who  had  both  vaginal  and  caesarean  deliveries  was  to  gain  a  thorough  understanding  of  women’s  perspectives  arising  from  a  variety  of  birth  experiences.     My  exclusion  criteria  encompassed:  (a)  Women  with  any  chronic  medical  or  mental  illnesses;;  (b)  women  who  had  delivered  preterm  infants  or  infants  with  congenital  anomalies;;  and  (c)  women  who  served  as  healthcare  professionals  in  direct  care  provision  for  labouring  women  (i.e.  obstetricians,  anesthesiologists,  nurses,  midwives,  and  doulas).  I  excluded  healthcare  providers  from  the  sample  to  ensure  that  I  captured  perceptions  of  women  who  had  not  been  embedded  in  the  cultural  nuances  of  hospital  birth  in  British  Columbia.        23    I  recruited  participants  by  posting  the  recruitment  letter  (Appendix  A)  on  the  VancouverMom’s  community  group  Facebook  page,  Kijiji©,  and  Craigslist©.  I  also  posted  the  recruitment  letter  around  the  UBC  campus  and  community  recreational  centres.    3.5  Sample  Selection     The  participants  in  my  study  represented  a  sample  of  convenience;;  however,  I  used  a  purposive  approach  (Thorne,  2008).  Purposive  sampling  relies  on  participants  who  can  help  us  better  understand  the  areas  of  inquiry  (Thorne,  2008).  The  women  varied  in  terms  of  the  nature  of  their  primary  care  providers,  models  of  maternity  care  received  while  in  hospital,  and  their  values  and  attitudes  about  the  medical  model  of  maternity  care.  Although,  the  women  were  a  demographically  homogeneous  group,  the  participants  consisted  of  phenomenally  diverse  cases  (Sandelowski,  2000);;  phenomenally  diverse  cases  represent  differences  in  the  women’s  birth  and  labour  experiences  which  provide  opportunities  to  learn  about  how  the  women  perceived  their  birth  environments  under  different  circumstances  (i.e.  birth  mode,  emergent  circumstances,  and  epidural  insertions).  I  sampled  women  who  had  given  birth  in  a  variety  of  hospitals  from  the  lower  mainland,  a  region  that  holds  54%  of  British  Columbia’s  population  (Environmental  Reporting  BC,  2016).      After  interviewing  fifteen  women,  I  achieved  data  redundancy.  This  was  the  point  at  which  I  obtained  critical  mass  of  data  from  my  interviews  that  yielded  no  new  information  from  further  interviews  related  to  my  identified  themes  (Polit  &  Beck,  2012).  According  to  my  study  procedures,  I  performed  data  analysis  from  the  inception  of  my  data  collection.  Concurrent  data  collection  and  analysis  enabled  me  to  compare  and    24 contrast  interviews  to  identify  the  salient  themes  and  evaluate  data  redundancy  (Elo  et  al.,  2014). 3.6  Data  Collection     Demographic  data  were  collected  after  the  interviews  were  completed  using  my  demographic  questionnaire  (Appendix  C).  I  collected  information  about  participants’  education  level,  occupation,  age,  mode  of  birth,  newborn  gender  and  health  status,  the  presence  of  a  live-­in  partner,  and  the  average  family  income.       I  collected  qualitative  data  using  semi-­structured  interviews  with  a  series  of  open-­ended  questions  from  my  interview  guide  (Appendix  D).  I  asked  questions  that  encouraged  participants  to  describe  what  they  perceived  as  the  effects  of  their  birth  environments  on  their  perceptions  of  FOC.  I  followed  the  participants’  lead  if  they  introduced  information  that  was  not  part  of  the  semi-­structured  interview  but  was  relevant  to  the  study  aim.  Based  on  my  early  analysis  of  some  interviews,  I  used  probing  questions  to  guide  participants  to  share  in-­depth  information  about  their  birth  experiences.  Examples  of  my  early  probing  questions  included:  Did  you  enter  the  hospital  prior  to  arriving  during  your  intrapartum  stay?;;  Did  you  attend  a  hospital  tour?;;  What  were  your  perceptions  of  the  events  that  led  to  the  progression  of  pain  management  plans,  or  of  labour  progression  plans?;;  If  an  emergency  moment  occurred,  what  was  decided  for  management  of  this  plan  and  how  was  it  decided?;;  What  were  the  effects  of  these  decisions  and  how  this  planning  occurred?;;  and  How  did  the  decision-­making  processes  influence  your  feelings  of  safety,  comfort,  or  fear?  My  modified  interview  guide  was  developed  and  used  in  subsequent  interviews  as  I  created  the  major  themes.  I  have  included  an  example  (Appendix  E).      25    I  performed  the  interviews  at  least  6  weeks  after  the  women  had  delivered  their  newborns.  The  literature  supports  my  approach,  by  indicating  that  a  six-­to-­eight  week  period  after  birth  is  an  appropriate  time  frame  to  wait  before  interviewing  women  who  have  given  birth  (Martin  &  Fleming,  2011).  Martin  and  Fleming  argued  that  women  require  time  to  physically  heal  from  birth  and  to  reflect  on  their  birth  experiences.  The  time  from  the  participants’  births  to  the  timing  of  interviews  ranged  from  six  weeks  to  three  years.  I  included  some  participants  who  were  three  years  beyond  their  births  because  they  were  very  anxious  to  talk  about  the  effects  of  hospital  births  on  their  birth  experiences  and  it  is  clear  from  the  literature  that  women  have  vivid  memories  of  their  birth  experiences,  even  years  after  the  events  occur  (Simkin,  1991).       All  of  the  interviews  were  digitally-­recorded.  I  interviewed  all  of  the  participants  in  a  location  of  their  choice.  Some  women  chose  to  meet  in  their  homes,  while  others  preferred  to  meet  in  coffee  shops  of  their  own  choosing.  In  addition,  some  women  brought  their  children  to  the  interviews.  The  transcribed  data  and  recorded  information  were  stored  in  files  on  an  encrypted  memory  stick  and  any  hard  copies  were  stored  in  a  locked  cupboard  in  the  principal  investigator's  (PI)  office.  All  identifying  elements  within  the  data  set  were  removed  and  pseudonyms  were  applied  to  preserve  confidentiality  for  participants.    3.7 Data Analysis    Data  analysis  consisted  of  concurrent  inductive  content  analysis;;  inductive  analysis  enabled  me  to  construct  patterns  and  themes  from  the  data  (Sandelowski,  2000).  I  achieved  thematic  development  by  immersion  in  the  data  (transcripts  and  reflexive  notes).  I  read  the  interviews  numerous  times  and  identified  codes  that  represented  participants’  comments  in  the  data  set  (Sandelowski,  2000).  This  process  is    26 highly  iterative.  Because  I  was  conducting  concurrent  inductive  analysis  I  initiated  the  process  during  the  early  stages  of  data  collection.       I  documented  coding  procedures  by  using  memos  and  reflective  notes.  Because  the  coding  was  performed  in  conjunction  with  the  data  collection  phase  I  was  able  to  develop  probing  questions  for  subsequent  interviews.  I  used  memos  to  describe  the  codes  and  cluster  them  into  common  categories  (Appendix  F  &  Appendix  G).  After  I  created  the  categories,  I  compared  and  contrasted  the  categories  to  develop  themes  and  specify  their  relationships.  Those  activities  captured  hospital  environmental  factors  affecting  women’s  perceptions  of  FOC.  I  kept  an  organized  and  coherent  record  of  interview  data.  Because  I  transcribed  all  of  the  interviews  I  was  very  familiar  with  the  interview  content  which  aided  my  systematic  thematic  development  (Sandelowski,  2000).       The  early  codes  that  I  developed  were  closely  linked  to  the  descriptions  women  provided  in  the  interview  data.  They  comprised  foreign  and  unfamiliar  beginnings,  pain  management  plans,  continuously  present  expert  caregiver,  hospital  rooms  and  equipment,  uncertainty,  and  attitudes  about  intrapartum  care  models  relating  to  fear.  I  clustered  the  codes  into  broader  categories,  which  included:  Foreign  and  unfamiliar  clinical  procedures  and  processes,  women’s  expectations  influencing  their  feelings  of  affinity  towards  hospital  birth  environments,  emergency  procedures  influencing  feelings  of  fear,  feelings  of  helplessness  resulting  from  times  of  uncertainty  and  loss  of  control,  and  times  of  uncertainty  influencing  feelings  of  fear.  I  described  those  categories  in  my  second  memo,  Parts  1  and  2  (Appendix  F  &  Appendix  G).      27    Finally,  I  clustered  the  categories  and  examined  links  between  them  to  construct  the  major  theme  and  six  subthemes.  The  major  theme  was  women’s  engagement  in  their  labours  and  births.  The  six  subthemes,  which  supported  the  major  theme,  were:  Women’s  connections  to  their  bodies,  women’s  inclusion  in  decision-­making  processes,  freedom  to  use  the  hospital  space,  feelings  of  trust  toward  professional  caregivers,  distractions  from  labour,  and  personalized  care.    3.8  Rigor     I  prepared  a  thorough  audit  trail,  which  is  a  “systematic  collection  of  materials  and  documentation  that  allow[s]  an  independent  auditor  to  come  to  conclusions  about  the  data”  (Polit  &  Beck,  2012,  p.591).  To  achieve  this,  I  compiled  all  raw  data,  analysis  products,  process  notes,  materials  about  my  intentions  and  dispositions,  and  drafts  of  the  chapters  (Polit  &  Beck,  2012).  A  clear  decision  trail  illustrating  my  study  plans  and  practices  including  interview  procedures,  as  well  as  data  analysis  plans  and  actions  were  created  in  the  form  of  memos  (Appendix  F  &  Appendix  G)  and  reflective  notes  (one  example  of  a  reflective  note  can  be  referred  to  in  Appendix  H).       I  obtained  thick  descriptions  from  all  of  study  participants  through  the  semi-­structured  interviews,  so  that  I  and  my  supervisor  could  derive  relevant  code  clusters  and  categories  from  the  data  to  assist  in  answering  our  research  question.  By  collecting  information  from  women  who  had  a  variety  of  experiences  during  their  intrapartum  hospital  stays,  I  was  able  to  increase  the  variability  of  the  data  available  for  analysis.       The  transferability  of  findings  is  demonstrated  by  the  shared  experiences  and  messages  of  each  participant  and  is  useful  to  other  users  and  health  care  providers  of  local  maternity  services.  Hospital  birth  environments  here  are  of  a  specific  user  context    28 and  the  stories  and  subsequent  themes  that  were  constructed  speak  to  that  context  (Sandelowski,  2004).      Observer  bias  is  an  element  of  the  research  process  that  requires  enactment  of  reflexivity.  Observer  biases  often  occur  if  emotions,  prejudices,  and  values  of  observers  result  in  faulty  inference  (Polit  &  Beck,  2012).  I  made  reflexive  notes  (Appendix  H)  during  data  collection  and  analysis  to  identify  my  biases  as  they  occurred.  For  example,  I  heard  one  participant  discuss  what  it  was  like  to  interact  with  a  pre-­op  nurse  and  an  anesthesiologist  when  deciding  if  extra  support  persons  could  come  into  the  operating  room  during  her  caesarean  section.  The  nurse  told  the  woman  that  she  could  not  have  two  family  members  in  the  operating  room.  Subsequently,  the  anesthesiologist  said  it  was  okay.  I  reflected  on  what  she  had  said  and  realized  that  I  was  not  comfortable  hearing  about  this  interaction.  I  think  my  impulse  was  to  take  sides  with  the  nurses  for  some  unknown  reason.  However,  at  the  same  time,  my  compassionate  side  understood  that  the  woman  was  sharing  a  deep  need  she  had  regarding  the  course  of  her  care  and  support  in  the  operating  room.  I  reflected  on  the  focus  of  that  interview  data  being  about  how  the  woman  felt  as  a  result  of  the  interactions,  she  felt  afraid,  and  “ready  for  a  fight”  (P  5).  Realizing  this  made  it  less  important  for  me  to  be  concerned  about  whose  side  I  would  be  inclined  to  take,  if  I  had  been  present  and  more  concerned  with  the  woman’s  perception  during  that  interaction.  I  also  later  reflected  on  the  effects  of  my  biases  in  my  interpretation  of  the  data.  It  was  necessary  to  reflect  on  my  experience  as  a  labour  and  delivery  nurse  so  that  I  did  not  apply  it  to  the  woman’s  experiences.  I  prevented  observer  bias  by  digitally  recording  all  interviews  and  transcribing  them  verbatim  so  that  representations  of  the  interviews  were  available  for  data  analysis.  During  interviews,  I    29 did  not  attempt  to  correct  or  change  meaning  for  participants  if  I  was  surprised  or  disbelieving  about  their  labour  and  birth  events.  My  supervisor  reviewed  the  interview  transcripts  and  assisted  in  identifying  relevant  codes  and  categories  which  reduced  the  influence  of  my  emotions,  prejudices  and  values  in  the  final  interpretation  of  the  data.      I  avoided  imposing  my  own  perceptions  of  hospital  birth  environments  on  their  stories.  By  carrying  out  the  previous  activities,  I  worked  towards  reducing  the  influence  of  my  emotions,  prejudices,  and  values  on  the  interpretation  of  the  raw  data  for  analysis.  3.9  Dissemination     I  intend  to  disseminate  t  findings  from  my  study  through  parent  groups,  healthcare  professional  presentations,  and  a  peer-­reviewed  publication.  I  will  also  distribute  a  summary  of  findings  to  all  participants  in  the  study  along  with  a  thank  you  letter  (Appendix  I)  for  participating  in  my  study.   3.10  Summary       My  use  of  a  qualitative  descriptive  study  design  aligned  with  the  aim  of  my  study:  To  investigate  women’s  perceptions  about  effects  of  hospital  environments  on  their  perceptions  of  FOC  during  their  labours  and  births.  I  outlined  the  process  of  obtaining  ethics  approval.  I  described  my  inclusion  and  exclusion  criteria,  sample  selection,  data  collection  procedures,  and  data  analysis.  The  methods  chapter  included  my  attention  to  rigor  and  my  plans  for  dissemination  of  the  study  findings.  In  the  next  chapter,  I  present  the  study  findings.             30 4:  Findings  4.1  Introduction     In  this  chapter,  I  begin  by  describing  the  participants  demographic  characteristics.  I  then  present  my  findings,  beginning  with  my  major  theme:  Women’s  engagement  with  their  labours  and  births.  Following  that  section,  I  introduce  my  subthemes:  Women’s  connections  to  their  bodies;;  women’s  inclusion  in  decision  making  processes;;  freedom  to  use  the  hospital  space;;  feelings  of  trust  toward  professional  caregivers;;  distractions  from  labour,  and  personalized  care.  The  links  between  the  major  theme  and  the  subthemes  are  illustrated  throughout  the  chapter.   4.2  Sample  Characteristics     My  study  participants  consisted  of  15  women  who  were  between  the  ages  of  28  and  38;;  their  average  age  was  34  (See  Table  1).  All  women  had  given  birth  to  only  one  child  in  a  hospital.  Forty  percent  (N=6)  of  the  participants  delivered  by  caesarean  section;;  the  other  sixty  percent  delivered  vaginally.  One  woman  gave  birth  via  an  instrumental  vaginal  delivery.  Forty-­six  percent  (N=7)  of  the  participants  had  been  receiving  care  from  a  midwife  during  their  pregnancies  but  required  a  consult  for  care  from  an  obstetrician  while  in  hospital.  Twenty  percent  (N=3)  of  the  women  received  midwifery  care  and  the  support  of  a  doula  while  in  hospital  without  an  obstetric  consult.  In  addition,  twenty  percent  (N=3)  of  the  participants  had  an  obstetrician  as  their  primary  care  provider  for  labour  and  birth,  and  thirteen  percent  (N=2)  of  the  women  were  receiving  care  from  a  general  practitioner.  Seventy-­three  percent  (N=11)  of  the  participants  reported  their  yearly  household  incomes  as  equal  to  or  above  $90,000  a  year.  The  majority,  ninety-­three  percent  (N=14),  of  study  participants  reported  living  with    31 a  partner.  This  sample  of  women  included  generally  highly  educated  women  with  all  achieving  a  college  diploma  or  university  degree.      Table  4.1  Sample  Demographics    Demographic	  Variables	   %	  (n)	  Maternal	  Age	  	  	  25-­‐30	   20	  (3)	  31-­‐35	   40	  (6)	  36-­‐40	   40	  (6)	  Household	  income	  	  	  $20,	  000-­‐34,	  999	   6.7	  (1)	  $35,	  000-­‐49,	  999	   0(0)	  $50,	  000-­‐74,	  999	   6.7	  (1)	  $75,	  000-­‐89,	  999	   13.3	  (2)	  ≥$90,	  000	   73.3(11)	  Maternal	  Education	  	  	  Diploma	   13.3	  (2)	  Degree	   46.7	  (7)	  Masters	   33.3	  (5)	  Doctorate	   6.7	  (1)	  Mode	  of	  delivery	  	  	  Vaginal	  birth	   53.3	  (8)	  Instrumental	  Vaginal	  birth	   6.7	  (1)	  Elective	  caesarean	  section	  birth	   6.7	  (1)	  Emergent	  caesarean	  section	  birth	   40	  (6)	  Living	  situation	  	  	  Lives	  with	  partner	   93.3	  (14)	  Lives	  as	  single	  parent	  	   6.7	  (1)	      4.3  Women’s  Engagement  with  Their  Labours  and  Births     The  major  theme  constructed  from  the  data  is  entitled:  Women’s  engagement  with  their  labours  and  births.  Women’s  engagement  with  their  labours  and  births  in  hospital  was  linked  to  their  feelings  of  fear;;  their  sense  of  fear  was  enhanced  when  they    32 felt  disengaged  throughout  their  experiences.  This  was  because  some  women  felt  fear  of  the  unknown  when  they  did  not  feel  engaged  with,  connected,  or  included  in  the  hospital  processes  surrounding  their  labours  and  births.         Participants  linked  their  difficulty  with  being  engaged  in  their  labours  and  births  to  particular  conditions  during  their  hospital  births.  They  described  conditions  that  decreased  their  feelings  of  control  and  connection  to  their  bodies,  which  contributed  to  feeling  disengaged  from  their  labours  and  births.  When  they  regarded  the  care  they  received  as  impersonal  and  they  felt  that  they  were  being  excluded  from  the  process  by  the  professional  caregivers  the  women  indicated  they  disengaged.      All  of  the  information  he  was  giving  me  about  the  emergency  c-­section…he  was  across  the  room  and  it  was  like  he  was  speaking  over  a  couple  of  nurses,  kind  of  thing…and  telling  the  nurses  what  they  were  going  to  do,  not  us.  (P  8)       The  women  described  mistrust  toward  their  caregivers,  which  contributed  to  feelings  of  fear,  if  caregivers’  models  of  care  did  not  align  with  their  personal  preferences  for  labour  and  birth,  and  if  the  caregivers  did  not  include  them  in  discussions  about  plans  for  labour  management.  The  women  described  feeling  unsafe  or  anxious  in  those  circumstances.    But  they  wanted  me  to  like  sit  on  it  on  the  bed,  and  I  was  like,  I  am  way  too  high,  like  I  don’t  feel  safe  so  I’ll  do  this  on  the  ground  but  I’m  not  doing  this  on  the  bed,  like  you  wouldn’t  let  a  child  do  this,  why  would  you  let  me  do  this…  I  remember  thinking  like  this  is  not  safe…like  maybe  this  is  your  better  view  of  the  baby  if  it  comes  out  and  I’m  up  here  but  like  I’m  like  closer  to  the  ceiling  then  I  am  to  the  floor.  (P  4)    [There  was]  a  bit  of  anxiety  and  sadness  around  the  fact  that  when  he  emerged  into  the  world  neither  of  us  were  really  there,  like  I  was  there  but  not...  (P  8)      33 The  women  depicted  fear,  helplessness,  disappointment,  defeat,  discouragement,  loneliness  and  lack  of  positive  anticipation  for  their  births  when  they  disengaged  during  their  labours.         The  participants  indicated  that  they  had  challenges  engaging  with  their  labours  and  births  when  they  felt  disconnected  from  their  bodies.  They  felt  disconnected  from  their  bodies  when  people  in  the  environment  distracted  them  from  their  labours,  environmental  circumstances  disrupted  their  concentration,  or  they  described  being  overcome  by  worries  about  the  unknown.  Their  sense  of  disconnection  occurred  during  events  when  they  were  being  distracted  by  the  presence  of  strangers,  had  minimal  accommodation  for  their  privacy,  felt  as  though  they  weren’t  being  told  what  was  going  on  with  their  fetus  or  themselves,  and  experienced  minimal  tranquility  in  hospital  spaces.  When  the  women  felt  unwelcomed  in  hospital  spaces  and  had  to  wait  for  staff  to  welcome  them  as  guests  into  the  environments  they  become  distracted  from  their  labours  and  lost  touch  with  their  bodies,  which  contributed  to  their  feelings  of  fear,  helpless,  discouragement,  and  loneliness.    The  women  described  feeling  disengaged  during  their  labours  and  births  when  they  felt  they  were  being  done  to  rather  than  being  able  to  participate  in  their  care  and/or  that  the  care  they  received  was  procedural  rather  than  considering  their  personal  expectations.    When  the  surroundings  and  care  the  women  received  seemed  oblivious  to  their  states  (i.e.  mental,  emotional,  and  physical)  participants  described  feeling  uneasy,  helpless,  and  disengaged  from  their  labours  and  births;;  these  feelings  resulted  in  fear  for  many  of  the  participants.      34    The  women  who  experienced  childbirth  fear  described  not  being  included  in  decision-­making  during  their  labours  and  births  in  hospital.  They  were  fearful  when  they  felt  inhibited  from  fully  engaging  with  their  labours  and  births  because  professional  caregivers  used  their  professional  power  to  act  on  them  without  including  their  perspectives.  The  caregivers’  knowledge  about  the  hospital  environments  and  clinical  procedures,  and  their  power  to  decide  on  care  plans  without  consistently  collaborating  with  the  women  or  putting  them  at  the  centre  of  their  births  increased  the  women’s  fear  and  reduced  their  abilities  to  engage  with  their  labours  and  births.    The  doctor  came  in…and  checked  me,  um  and  the  baby’s  heart  rate  was  going  back  up,  and  she  said  okay  I  want  to  break  your  waters  so  you  can  have  stronger  contractions,  well,  [I  said]  there’s  nothing  I’ve  read  that  tells  me  that’s  a  thing  that  happens  [the  doctor  said]  I  don’t  understand  why  you’re  fighting  with  me,  you  might  as  well  benefit  from  stronger  contractions  while  you’re  here,  okay,  so  she  broke  my  water.  (P  15)    When  participants  felt  constrained  in  their  use  of  hospital  space  they  felt  uneasy  and  helpless  which  reduced  their  abilities  to  engage  in  their  labours  and  births.  All  of  the  women  in  my  study  described  their  hospital  environments  as  being  controlled  by  professionals,  which  contributed  to  them  feeling  that  they  needed  to  wait  to  be  given  suggestions  and  offers  about  using  the  space,  which  reduced  the  women’s  feelings  of  control.  Whether  participants  felt  professionals  held  the  control  was  not  related  to  who  their  primary  care  giver  was  (i.e.  midwife,  general  practitioner,  or  obstetrician);;  it  was  related  to  whether  health  care  providers  listened  to  them.  If  the  women’s  wishes  were  ignored  (impersonal  care)  they  felt  helpless  and  lacking  control  from  the  time  they  entered  the  hospital,  which  contributed  to  their  fear.      35 But  it…nobody  suggested  it  and  [it]  seemed  like  I  couldn’t  [get  out  of  bed  and  use  the  exercise  ball]…I  don’t  know  exactly  why,  like  I  didn’t  feel  like  I  had  the  freedom  to  do  it,  like  uh…almost  like  the  permission  to  do  it.  (P  7)    When  participants  expressed  mistrust  towards  care  providers  they  regarded  the  environments  as  being  controlled  by  the  professionals,  with  professionals  acting  out  plans  or  making  decisions  where  the  women  had  no  control.    Those  conditions  not  only  inhibited  participants  from  being  engaged  with  their  labours  and  births  but  also  increased  their  uncertainty  and  fear.  They  linked  their  fear  and  concern  to  the  professionals  failing  to  give  adequate  explanations  or  to  conduct  follow-­up  discussions  with  them  after  the  births  of  their  babies.  They  also  described  feeling  fear  and  concern  during  instances  when  professional  caregivers  appeared  to  have  made  a  mistake.  Some  participants  said  this  made  them  feel  like  they  were  being  acted  on  rather  than  having  others  collaborate  with  them  around  their  labours  and  births.  Their  perceptions  of  lack  of  collaboration  provoked  feelings  of  fear  for  their  safety  and  of  possible  upcoming  discomfort  or  pain  related  to  labour  and  birth  or  interventions.    I  was  watching  her  and  I  was  like  oh  god  it  is  taking  her  forever  to  get  to  the  door,  it  was  like,  literally  the  door…um  she  marched,  she  didn’t  say  anything,  but  she  didn’t  look  distressed  or  anything  she  just  sort  of  got  up  and  walked  out…I’m  like  there’s  gotta  be  an  emergency  button  on  the  outside  of  that  door,  she  walked  out,  she  walked  back  in  I  don’t  think  she  said  anything,  she  came  and  she  sat  down  beside  me,  and  then  in  like  20  seconds  there  were  like  8  people  in  the  room.  (P  9)       Participants  who  felt  that  they  were  not  receiving  personalized  care  felt  disconnected  from  the  environments.  In  those  instances,  the  women  described  the  care  providers’  approach  to  their  work  in  hospitals  as  not  incorporating  the  women  as  the  focus  of  the  care.  Participants  who  were  uneasy,  anxious,  and  fearful  received  a  clear  message  from  professional  caregivers  that  the  environment  was  oriented  towards  the    36 caregivers’  directives  and  tasks  for  managing  labours  and  births  safely  without  attending  to  the  women’s  experience.  When  participants  described  care  providers’  failures  to  take  their  experiences  into  account  they  felt  slotted  in  like  someone  waiting  in  line  at  a  delicatessen.  The  women  indicated  that  this  contributed  to  them  feeling  isolated  and  that  they  were  insignificant,  which  created  doubts  about  what  would  happen  during  their  labours  and  births.    I  just  felt  like  maybe  that  step  could  have  been  done  at  a  different  time,  maybe,  maybe  if  the  different  policies  and  procedures,  get  upstairs,  get  settled…I  don’t  know  maybe  your  midwife  can  help  facilitate  the  check  in,  but  yes,  it  did  seem  impersonal  but  that’s  why  I  said  like  maybe  the  receptionist  is  doing  this  all  day  so  your  just  another  person  walking  through  the  door…um…  it’s  not  a  super  warm  fuzzy  welcoming  certainly…  (P  10)    Caregivers’  focus  on  control,  directives,  and  tasks  for  managing  the  women’s  labours  and  births  safely,  but  not  in  a  personalized  way,  contributed  to  the  women’s  feelings  of  mistrust  toward  caregivers.  Without  trust  for  caregivers,  the  women  indicated  they  could  not  engage  with  their  labours  and  births  because  they  believed  that  their  expectations  for  their  births  might  be  violated;;  risks  of  violating  expectations  made  them  feel  fearful  and  defensive.  The  women  indicated  that  when  they  had  a  sense  that  their  expectations  did  not  matter  to  the  caregivers  they  felt  less  security  and  more  fear.         So  I  was  afraid  about…having  to  have  an  unplanned  section,  because  they  said  at  that  hospital  the  recovery  is  separate,  so  you  can’t  be  with  your  newborn,  and  they  said  in  some  hospitals  you  can…  that  made  me  afraid,  because  I  wanted  a  certain  kind  of  like…  I  was  planning  for  an  intervention  free  delivery  and…I  didn’t  want  to  have  to  have  um  a  section  and  especially  there  because  then  I  knew  I  would  be  away  and  not  have  skin-­to-­skin  for  they  said  two  to  four  hours  so  that’s  what  I  was  afraid  of.  (P  4)    When  the  women  described  feeling  disengaged  from  their  labours  and  births,  they  depicted  feelings  of  fear,  defeat,  helplessness,  disappointment,  discouragement,    37 loneliness,  and  a  lack  of  positive  anticipation  for  their  labours  and  births.  They  regarded  their  expectations  for  their  labours  and  births  as  being  violated;;  in  what  follows,  I  describe  each  sub-­theme,  beginning  with  the  women’s  connection  to  their  bodies.      4.3.1  Women’s  Connections  to  Their  Bodies   The  women  felt  disconnected  from  their  bodies  and  fearful  when  they  could  not  focus  on  what  their  bodies  had  the  capacity  to  withstand  in  regards  to  labour  pain  and  physical  stamina.  Without  opportunities  to  become  familiar  with  the  sensations  they  were  feeling  throughout  labour  the  women  indicated  that  they  lacked  control  and  engagement  during  their  labours  and  births.  In  cases  when  this  occurred,  some  participants  mentioned  that  their  caregivers  did  not  acknowledge  that  they  had  unique  preferences  about  how  they  would  perform  birth.  They  depicted  being  fearful  when  particular  phenomena  arouse,  when  they  were  not  given  the  opportunity  to  appreciate  what  the  sensations  in  their  bodies  were  signaling  to  them,  and  their  feelings  related  to  the  ultimate  delivery  of  their  babies  were  not  respected.    I  remember  being  stressed  out  about  my  own  contractions  but  then  the  sound,…that  was  one  thing  that  really  added  to  my  stress  like  hearing  someone  [in]  like  full  blown  active  labour  as  I  was  trying  to  sort  of  work  through  my  own  pain  and  knowing  like  I  am  already  in  a  lot  of  pain  at  this  point  and  like  that’s  what’s  coming,  even  though  the  nurse  was  like  trying  to  reassure  me  that  that  was  probably  something  kind  of  special  because  they  were  having  an  extremely  fast  labour  but  the  fact  that  I  could  hear  someone  else  giving  birth  ya.  (P  2)         When  elements  of  the  hospital  birth  environment  distracted  the  women  from  their  foci  they  felt  more  restless  and  anxious  which  contributed  to  their  fear.  Their  restlessness  distracted  participants  from  the  bodily  sensations  that  they  were  having  which  they  linked  to  feeling  disconnected  from  their  bodies.  These  circumstances  arose    38 at  times  when  they  did  not  receive  explicit  reassurances  about  the  successful  delivery  of  their  infants  from  their  caregivers.    Everyone  you  see  who  is  in  charge,  the  nurses,  the  midwife,  are  all  telling  me  I  can’t  do  it…Like  so  frustrating…[it]  didn’t  add  any  value  [sighs  in  awe]  …to  my  ability  to  deal  with  it,  being  told  you  can’t  do  it  is  just  so  discouraging.  (P  1)  Participants  described  what  it  was  like  to  move  from  circumstances  at  home  where  they  were  comfortable  and  coping  in  their  familiar  spaces  to  the  hospitals  where  they  encountered  foreign  elements  of  the  physical  space.  In  hospital  spaces,  especially  in  the  triage  areas,  the  women  experienced  barriers  to  being  comfortable  and  able  to  cope,  the  women  described  feeling  disoriented  and  having  things  done  to  them  that  reduced  their  feelings  of  control  and  increased  their  fear.  When  somebody  is  coming  to  put  a  blood  pressure  cuff  on  you,  [are]…physically  anchored  to  a  spot  and…I  had  to  have  my  blood  sugar  tested  repeatedly  because  I  had  Gestational  Diabetes….so  when  people  are  constantly  coming  to  do  these,  um,  small  tests  on  you  it  feels  like,  like  you  almost  have  to  ask  permission  to  get  up…can  I  move,  but  if  you’ve  already  lost…the  feeling  of  control…  (P  7)    Fearful  participants  linked  their  difficulties  staying  connected  to  their  bodies  to  unfamiliar  spaces  and  structures  that  did  not  fit  with  their  personal  physical  needs.  Participants  who  described  health  care  providers  orchestrating  where  and  how  they  would  be  during  their  labours  and  births  felt  more  fearful  particularly  when  health  care  providers  expressed  needs  to  closely  monitor  them.  Some  participants  described  feeling  stuck  in  the  spaces,  nervous,  and  unsettled  by  their  surroundings.    I  didn’t  know  who  I  was  spending  time  with,  and  the  staff  are  very,  you  know  they’re  not  engaged  at  a  personal  level  at  all,  it’s  very  clearly  just  their  job,  and  they  have  no  other  concern  other  than  doing  their  job.  (P  13)    39 Participants  who  felt  disconnected  from  their  bodies  described  difficulty  articulating  what  they  needed  from  their  professional  caregivers.  They  found  it  hard  to  decide  if  they  should  speak  up  about  particular  discomforts  or  personal  preferences  because  they  became  uncertain  about  the  legitimacy  of  what  they  needed  and  felt  out  of  control  and  lonely.  Under  circumstances  where  professional  caregivers  were  leading  the  course  of  care  and  seemed  to  take  ownership  of  the  women’s  bodies  they  described  feeling  less  connected  to  their  bodies  and  fearful.      Um  I  felt  very  much  not  heard,  um  I  felt  very  disregarded  um…and  I  do  not  like  that  [nurse],  I’ve  never  seen  her  since,  but  I  have  very  negative  feelings  toward  her,  it  just  felt  like  she  didn’t  trust  me  to  know  what  was  going  on  with  my  body.  (P  15)         Participants  gave  examples  of  their  caregivers  not  allowing  them  to  listen  to  their  bodies;;  because  it  seemed  to  them  that  caregivers  did  not  trust  the  women’s  bodies.  In  these  cases,  they  felt  more  fearful  and  lost  confidence  in  themselves.        I  didn’t  like  the  contraption  in  my  mouth  [Nitrous  Oxide]  [R:  Hmm]  um  and  I  remember  a  different  nurse  came  in  and  she  almost  forced  it  on  me  the  second  time,  she  was  like  no,  I  think  you  really  need  to  try  it  as  I  was  going  through  the  contractions,  and  um…I  tried  it  again  I  don’t  know  why  I  kind  of  let  her…kind  of  push  me  into  it.  (P  14)      The  women  indicated  that  they  were  disconnected  from  their  bodies  and  felt  fear  when  they  were  experiencing  suffering  with  their  pain  and  could  not  focus  inwardly  to  cope  with  the  pain  of  contractions.  Their  suffering  and  fear  were  enhanced  by  the  failure  of  professional  caregivers  to  acknowledge  their  abilities  to  cope.  For  example,  one  woman  said  that  she  experienced  very  constant  pain  in  her  back  that  did  not  diminish  between  contractions.  She  indicated  that  she  was  fearful,  ashamed,  and  felt  out  of    40 control  because  she  did  not  know  why  her  body  was  experiencing  labour  this  way;;  she  received  little  acknowledgement  from  staff  members  about  her  experience:   [It  enhanced  my  sense  of  fear]  …I  felt  like  I  was  behind  a  veil  like,  I  am  having  all  these  huge  emotions  and  I’m  terrified  and  then  you’re  so  calm  it  makes  me  feel  like  I  should  be  ashamed  of  feeling  so  out  of  control…I  think  I  would  have  felt  better  if  someone  [would]  have  just  went  holy  shit  this  is  hard,  you  are  in  pain  this  is  so  hard  for  you.  (P  1)       When  a  woman  was  experiencing  labour  pains  and  realized  that  nothing  could  have  prepared  her  for  the  pain  she  was  experiencing  she  indicated  that  her  feelings  of  loss  of  control,  connection  to  her  body,  and  fear  were  reduced  when  her  nurse  validated  that  her  labour  was  very  strong. Uh  decreased  [fear]…acknowledgement  from  my  nurse…that…  I  had  progressed  quickly  and  severely  and…  that  was  acknowledged  from  her  that  she  didn’t  dismiss  that,  that  I  wasn’t  just  being  a  baby  and  that  she  uh  acknowledged  that  I  was  in  distress  and  not  coping  well.  (P  3)         Participants  who  felt  uncomfortable  being  disconnected  from  their  bodies  during  labour  and  birth  expressed  feeling  uneasy,  which  contributed  to  their  fear.  The  women  explained  how  hospital  procedures  and  practices  drove  them  to  feeling  disconnected  from  their  bodies  because  they  felt  their  bodies  were  out  of  their  control.  When  the  women  indicated  they  did  not  receive  options  for  coping  with  the  pain  and  intensity  of  their  labours,  they  felt  jarred  and  disassociated  from  their  bodies.   They  took  the  nitrous  away  which  was  very  sad  because  [laughs]  I  found  it  extremely  useful  um…it  was  kind  of  like,  a  bit  jarring  to  have  to  like  actually  deal  with  the  contractions…[that]  made  it  even  a  little  bit  more  like…I  was  a  little  bit  outside  of  myself.  (P  6)    41 Having  things  done  to  them  and  their  bodies  by  professional  caregivers  made  the  women  feel  afraid  of  what  was  going  to  happen  next,  which  they  linked  to  their  deep  uncertainty.    Initially  when  I  was  um…labouring  on  all  fours  I  felt  very  comfortable,  and  they  had  kind  of  asked  that  I  change  positions  um  more  to  on  my  side  or  on  my  back  so  that…that  made  me  fearful,  because  of  things  that  I  had  heard,  um  you  know  I  did  a  prenatal  class  and  I  had  friends  that  said  like,  don’t  push  on  your  back,  or  don’t  push  on  your  side  cuz  you’ll  tear,  and  da  da  da..so  I  became  ya  nervous  and  a  bit  fearful  of  that  I  kind  of  thought  no  no  no  I  shouldn’t,  I  shouldn’t  be  on  my  back,  that’s  not  going  to  work.  (P  12)    A  participant  who  had  been  receiving  care  from  a  midwife,  and  subsequently  received  consult  care  from  an  obstetrician  for  complications  related  to  prodromal  labour  described  things  being  done  to  her  that  reduced  her  feelings  of  agency.  She  felt  what  was  being  done  ‘to  her  body’  disconnected  her  from  it.  She  was  particularly  fearful  about  not  being  told  results  of  exams,  or  why  her  blood  pressure  was  being  checked.   I  mean  I  know  when  my  blood  pressure’s  being  taken  but  they’re  not  always  explaining  what  exactly  is  going  on  and…when  they  assess  how  far  dilated  [you]  are…so  that’s  when  it  starts  to  feel  uh  confusing,  and  like,  almost  more  like  you’re  being  acted  on  than  in  control  of  the  situation.  (P  7)       Under  circumstances  where  the  women  felt  disconnected  from  their  bodies  the  women  depicted  increased  feelings  of  uncertainty  about  their  labours  and  births,  which  made  them  feel  afraid.  They  described  being  afraid  that  they  could  not  cope  during  their  labours  and  births,  further  increasing  their  sense  of  disconnection  and  feelings  of  fear.  They  indicated  that  fear  could  be  reduced  by  information  and  suggestions  about  care  from  their  caregivers,  which  helped  them  feel  more  connected  and  better  able  to  cope  with  their  labours  as  their  pain  increased  and  their  experiences  intensified.    42 4.3.2  Women’s  Inclusion  in  Decision-­making  Processes     The  women  indicated  that  they  felt  fearful  during  their  labours  and  births  when  they  were  excluded  from  decision-­making  processes;;  they  felt  that  they  were  losing  control  over  their  births,  which  made  them  fear  the  unknown.  Participants’  limited  inclusion  in  decision-­making  processes  and  heightened  fear  reduced  their  engagement  with  their  labours  and  births.  They  described  many  times  when  the  health  care  providers  made  decisions  about  the  courses  of  their  care  in  hospital  and  they  felt  that  their  autonomy  was  undermined  because  they  had  no  understanding  of  events,  or  were  not  included  in  decisions.    So…that  was  my  my  initial  fear…I  was  so  already  heavily  into  it  that  I  wasn’t  processing  to  ask  the  question  like  how  long  am  I  going  to  be  alone  for,  when  are  you  coming  back?  What  happens  from  here?…I  found  myself  alone  in  the  [hospital]  room  like  sitting  on  the  toilet,  throwing  up  into  a  bucket  and  just  being  afraid.  (P  3)         Participants  experienced  fear  and  concern  when  they  perceived  independent  decision-­making  by  health  care  professionals  as  the  professionals’  use  of  power  over  them.  The  women  indicated  unhappiness  about  professional  caregivers  making  decisions  about  elements  of  their  labours  and  births  that  they  regarded  as  being  within  their  own  realm  of  their  understanding.  Participants  who  felt  well  informed  believed  that  they  should  have  been  included  in  decision  making  processes.  The  participants  became  very  alarmed  when  professional  caregivers  gave  them  the  impression  that  they  were  not  welcome  to  participate  in  decision-­making  processes.    My  doctor  won’t  allow  me  to  go  past  39  weeks,  and  I’m  like  that’s  not  his  decision  obviously  he  knows  more  about  medical  stuff  than  you  do  so  like,  talk  to  him,  but  there’s  no  such  thing  as  won’t  allow  you  to…it’s  your  body,  so  when  she  said  you  know  once  you  check  in  here  you  are  on  our  timeline,  that  was…partly  scary  in  terms  of  knowing  that  I  was  going  to  be  pushed  in  certain  directions.  (P  15)    43      The  participants  also  regarded  abuse  of  power  as  occurring  when  professional  caregivers  carried  on  conversations  about  them  and  possible  labour  and  birth  management  techniques  without  including  them  in  their  conversations.  Those  actions  enhanced  their  feelings  of  loss  of  control.  In  particular,  some  participants  described  professional  caregivers  making  decisions  about  what  positions  they  should  be  in,  which  non-­pharmacological  labour  interventions  were  available,  which  individuals  would  be  present  during  their  labours  and  births,  and  which  methods  of  augmentation  would  be  used  (e.g.  nipple  stimulation  vs.  intravenous  oxytocin).    I  said  okay  what  are  my  options  and  she  said  well  we  can  hook  you  up  to  a  breast  pump  to  try  and  get  some  of  this  stimulations  going.  And  I  was  like  oh  okay,  cuz  that’s  not  a  clinical  intervention  so  okay.  And  she  said  or  we  can  give  you  an  epidural  to  help  move  things  along,  and…[I]  don’t  remember  thinking  at  the  time…but  that’s  not  the  way  I  wanted  my  birth  plan  to  go  and  I  wasn’t  with  it  enough  to  say  you  know,  “come  on  are  there  any  other  options?”,  but  in  that  state  of  mind  it’s  very  hard  to  advocate  for  yourself.  (P  11)    The  participants  described  feeling  out  of  control,  fearful  and  disengaged  from  their  births  when  caregivers  imposed  limitations  on  their  involvement  in  decision-­making  by  having  technical  conversations  that  excluded  them.  No  opportunities  for  them  to  discuss  options,  with  professionals  taking  over  decision-­making  and  enacting  clinical  interventions,  made  the  women  feel  fearful  and  anxious.  They  described  caregivers’  communication  as  short,  repeated,  unfeeling  positive  words  for  example,  “everything’s  going  to  be  fine”  (P  8),  “the  machine  is  just  giving  us  trouble.  Everything  is  fine”  (P  8).  Those  forms  of  communication  contributed  to  the  women  feeling  uncertain  and  afraid  of  the  unknown.      44   I  don’t  [know  what]  vaso  vagal  episode  is  [laughing]  and  they  seemed  really  really  concerned  about  that  and  uh  if  they  hadn’t  used  the  jargon  I  could  have  said  that  honestly  that  does  happen  to  me  quite  often…I  wasn’t  particularly  concerned  at  all  but  they  were  hugely  concerned  about  it  so  then  they  dropped  me  back  down  to  laying  down…had  me  push  that  way  but  it  was  a  really  unproductive  way  to  push,  and  once  again  nobody  had  ever  suggested  any  other  positions.  (P  7)       The  women  linked  times  where  the  professional  caregivers  glossed  over  complex  decisions  by  providing  bias-­laden  suggestions  and  comments  to  their  feelings  of  lack  of  trust,  lack  of  power,  and  being  out  of  control,  which  interfered  with  their  abilities  to  stay  connected  to  their  bodies  and  engage  with  their  labours  and  births.  They  described  being  afraid  of  the  unknown.  Having  professional  caregivers  make  what  the  women  regarded  as  leading  or  suggestive  comments  gave  them  the  impression  that  the  caregivers  were  imposing  their  care  preferences  on  them.  Caregivers’  impositions  undermined  the  women’s  feelings  of  trust.       The  women  linked  care  being  imposed  on  them  to  feeling  disengaged  from  their  births  and  defeated  and  fearful  about  possible  bad  outcomes  resulting  from  imposed  labour  management  decisions  (e.g.  purple  pushing,  or  pushing  in  uncomfortable  positions).       The  participants  indicated  that  a  common  decision  over  which  professional  caregivers  had  control  was  the  timing  of  their  admission  to  hospital,  which  occurred  after  the  women  came  in  for  their  initial  assessments.  The  women  who  arrived  at  the  hospital  in  early  labour  and  expected  to  be  admitted  described  feeling  fearful  and  panicked  during  the  car  ride  to  the  hospital.  They  indicated  that,  if  they  went  home,  they  would  have  to  do  that  car  ride  at  least  two  more  times,  which  they  found  difficult  to  face.  The  participants  described  the  caregivers’  decisions  to  send  them  home  as  daunting    45 and  creating  panic  (e.g.  due  to  traffic  delays  and  concerns  of  them  not  being  able  to  get  comfortable  in  the  car  while  experiencing  contractions).  One  woman  said:      I  didn’t  want  to  be  in  the  car  having  contractions,  stuck  there,  out  of  control  don’t  know  what  I’m  doing,  maybe  it’s  just  me  and  my  husband,  so  that  was  a…level  of  anxiety   that   I’d  had…but   I  still  was  a  bit  nervous  that   I  wasn’t  going  to  be  4  cm  and  then  what,  what  happens,  do  I  drive  all  the  way  back  home?  (P  11)       Some  participants  described  their  feelings  that  their  caregivers  were  ‘closing  ranks’  or  ganging  up  on  them  to  take  the  power  for  making  decisions  about  their  labours  and  births.  Under  those  conditions,  they  indicated  that  they  lost  connection  to  their  labouring  bodies,  trust  for  their  caregivers,  and  sense  of  engagement  with  their  labours  and  birth.  They  described  their  expectations  of  their  births  slipping  away.  When  professional  caregivers  made  many  decisions  without  taking  the  women’s  preferences  into  account,  the  women  were  more  likely  to  depict  fear,  discouragement,  defeat,  and  helplessness.    When  you’re  faced  with  this…wall  of  people  who  have  made  it  clear  that  they  don’t  think  you  can  do  it…because  they  don’t  think  statistically  that  you  can  do  it,  that…they  don’t  support  you  in  trying  to  keep  doing  it…so  when  you’re  faced  with  a  wall  of  people  who  aren’t  going  to  help  you  do  the  thing  that  you  came  there  to  do  I  mean  you  just  have  to  surrender  in  defeat…and  these  terms  being  used  that  created  an  atmosphere  of  fear,  you  know,  stress  on  the  baby.  (P  7)      4.3.3  Freedom  to  use  the  Hospital  Space   The  participants  described  their  fears  that  they  were  losing  control  when  professional  caregivers  rather  than  the  women  had  the  power  to  control  how  the  women  used  the  hospital  space.  The  women  linked  loss  of  control  to  reductions  in  their  levels  of  engagement  with  their  labours  and  births.    They  were  also  still  having  trouble  keeping  the  IV  in  place  like  when  I  was  moving  around…um  and  I  think…also  I  had  to  have  a  …like  a  monitor,  and  so  there  were    46 certain  positions,  and  ya  actually  with  the  first  nurse  I  remember  her  being  much  more  prescriptive  in  like  the  positions  that  I…I..could  be  in,  um  she’s  like,  “oh  I  can’t  read  the  baby  as  well  in  that  positon,  you  can’t  do  that”  and  I  was  like…  “ohhh”.  um  and  I  didn’t  feel  as  much  that  she  was  suggesting  other  positions.  (P  12)       Being  exposed  to  procedures  and  processes  in  the  hospital  birth  environment  was  often  represented  by  the  women  as  their  loss  of  freedom  to  engage  with  or  control  the  space  associated  with  their  labours  and  births.  Participants  depicted  their  limited  freedom  in  hospital  spaces  when  student  doctors  and  nurses  imposed  clinical  acts  on  them.  They  indicated  that  they  were  often  made  to  wait  in  public  spaces  while  trying  to  cope  with  their  labour  contractions.  They  described  being  restricted  from  getting  out  of  bed  or  using  the  toilet  while  they  were  using  an  epidural.  Participants  also  linked  loss  of  freedom  to  being  restricted  in  their  pushing  positions  and  locations  during  the  second  stage  of  labour.  One  woman  described  fear-­inducing  feelings  from  not  having  freedom  to  move:      I  thought  it  was  terrible.  The  bench  was  very  uncomfortable…I  felt  like  I  didn’t  feel  anxious  at  all  until  I  got  to  that  point…like  having  no  idea,  kinda  what  was  happening  next…and  it  was  really  uncomfortable  like,  I’m  9  months  pregnant  my  back  is  already  killing  me  and  to  sit  on  that  that  wooden  bench…um  so  I  found  ya  I  got  more  and  more  irritated  and  anxious  and  kind  of  on  edge  the  longer  I  sat  there…(P  5)       When  the  women  linked  professional  caregivers’  clinical  procedures  and  restrictions  to  solely  risk-­oriented  and  medically  based  approaches,  they  regarded  their  power  to  act  in  the  process  of  labouring  and  giving  birth  as  limited,  which  made  them  fearful.  They  described  the  environment  as  under  the  power  of  professionals.  The  participants  indicated  that  they  felt  like  guests  with  limited  freedom  to  use  the  space  and  equipment.  The  women  felt  acted  upon  when  they  were  expected  to  participate  in    47 clinical  procedures  that  restricted  their  freedom  and  their  ability  to  have  control  over  their  situations.  Feeling  like  passive  participants  contributed  to  their  fear.  As  passive  participants,  the  women  perceived  their  labours  and  births  as  uncertain  or  disorganized.  They  described  a  sense  of  chaos  and  feelings  of  distrust  that  made  them  fearful  and  disconnected  from  their  bodies  and  disengaged  from  their  births.    Because  you  are  arriving  somewhere  where  you  are  going  to  put  your  trust  in…medical  professionals  who  are  going  to  help  you  with  this  difficult  thing  so  then  on  the  other  hand  um  it’s  a  very  cramped,  chaotic  space  and  you’re  kind  of  being  forced  into  this  um  cramped  physical  space  and  in  uncomfortable  ways.    (P  7)       The  women  linked  feeling  less  fearful  and  viewing  hospital  environments  more  favorably  to  their  abilities  to  control  using  the  beds  and  birthing  balls  and  nitrous  oxide.  When  they  exerted  that  control  they  felt  that  those  tools  supported  them  in  connecting  with  their  bodies  and  engaging  with  their  labours  and  births.  They  were  more  likely  to  express  trust  in  their  caregivers.  One  woman  described  her  situation  and  how  she  appreciated  being  able  to  use  the  hospital  space  for  her  labour,  They  gave  me  the  nitrous  oxide,…I  thought  man  if  I  had  to  labour  through  that…to  be  standing  up  for  every  contraction  or  getting  up  out  of  bed  every  contraction  I  would  had  like  been  really  really  exhausted…so  [it]…was  great  cuz  then  I  was  able  to  just  kind  of  lay  down  and  breath  through  the  contractions.  (P  6)        When  the  women  described  powerlessness  because  professional  caregivers  took  control  of  their  labours  and  births  they  felt  less  freedom  to  act  and  to  use  the  hospital  space.  Feeling  like  strangers  in  a  strange  land  resulted  in  participants  feeling  disconnected  from  their  bodies  and  unable  to  engage  in  their  labours  and  births.  Their  senses  of  disconnection  and  disengagement  increased  their  anxiety,  helplessness,  and  fear.      48 4.3.4  Feelings  of  Trust  Toward  Professional  Caregivers       The  women  described  feelings  of  disappointment  and  fear  when  their  caregivers  did  not  include  them  in  decision-­making.  They  depicted  caregivers  as  appearing  to  ignore  their  opinions  or  preferences.  Such  actions  were  associated  with  participants  reporting  mistrust  toward  their  professional  caregivers.    Lacking  trust  toward  professional  caregivers  contributed  to  the  women  having  difficulty  connecting  with  their  bodies  and  engaging  in  their  labours  and  births.  It  made  them  fearful.  Participants  described  feeling  that  they  had  to  be  on  the  defensive  with  their  caregivers,  fighting  for  validation  of  their  preferences  and  values,  or  fighting  for  control  over  their  labours  and  births,  which  left  them  worried  and  unsettled.  One  woman  described  her  thinking  as  she  navigated  conversations  with  her  primary  caregiver  for  whom  she  felt  mistrust:    So  just  sort  of  anticipating,  uncomfortable  and  kind  of  tedious  conversations,  trying  to  figure  out  when  to  push  back,  and  when  to  be  like  that  sounds  like  a  great  idea,  or  can  you  give  me  more  information  about  that  suggestion,  as  if  really  these  are  really  like  calm  civilized  conversations  that  you’re  having  while  you  are  in  labour.  (P  15)        Another  woman  explained  what  it  was  like  for  her  to  navigate  communication  with  her  caregivers  prior  to  her  caesarean  section:      If  he  wants  my  blood  pressure  to  be  a  170  over  100  then  leave  my  mom  out  of  that  room.  She  was  like  well  you’ll  have  to  talk  to  the  anesthesiologist…And  I  was  like,  bring  him  on  in.  So  I’m  at  this  point  a  little  pissed  so  I  felt  like  I  kind  of  got  set  up  at  this  point…I  felt  like  I  was  immediately  shut  down  when  I  said  I  wanted  my  mom  and  my  husband  in  that  room  as  a  support  system  you  know,  first  time  mom,  never  had  surgery,  never  had  a  baby…Like  my  support  system  is  very  important  to  me  and…she  set  me  up  to  be  more  nervous  to  be  even  more  anxious  to  ask  the  anesthesiologist.  (P  5)       Lack  of  trust,  usually  around  the  participants’  lack  of  inclusion  in  decision-­making  and  using  space,  increased  their  feelings  of  uncertainty  and  their  fear  of  the  unknown.    49 In  particular,  when  healthcare  providers  talked  about  the  women  in  their  presence  but  not  to  the  women  or  when  care  providers  left  the  room  to  talk  about  the  women  and  returned  without  clarifying  the  conversation  the  participants  indicated  that  their  trust  diminished  and  their  uncertainty  increased.    She  literally  just  assessed  me  and  then  left  the  room,  and  then  my  doula  left  too  for  a  moment,  I  guess  to  talk  to  her.  They  work  together.  They  know  each  other  they’re  part  of  the  birth  program  so  that  doula  has  worked  with  that  midwife  a  number  of  times  um,  and  that  was  it  like  and  then  she  was  gone.  (P  1)    The  women  described  enhanced  feelings  of  mistrust  when  caregivers  performed  assessments  and  tests,  without  discussing  the  rationale  for  the  tests,  or  their  results.  The  participants  also  depicted  less  trust  for  caregivers  in  situations  where  the  healthcare  providers  neglected  to  identify  themselves  before  providing  care.  The  women  indicated  that  encounters  with  healthcare  providers  who  performed  vaginal  exams  and  then  left  the  room  without  telling  them  their  findings  undermined  their  feelings  of  trust  and  reduced  their  sense  of  agency  and  control.  Participants  depicted  the  combination  of  decreased  trust  and  increased  feelings  of  lack  of  control  of  events  as  interfering  with  their  abilities  to  stay  connected  with  their  bodies  and  engage  in  their  labours  and  births.    So  when  nobody  at  any  point  ever  says  okay  we’re  done  all  the  tests  we  need  to  do,  we’re  done.  You  don’t  know  if  you  can  just  do  your  own  thing  or  not,  and  if  you  already  felt  like  you  lost  control  like  I  did  um  then  it’s  hard  to  kinda  like,  and  you’re  in  a  lot  of  pain  too.  It’s  hard  to  kinda  regain  that  agency.  It’s  hard  to  kind  of  regain  your  voice  and  have  that  moment  of  clarity,  because…it’s  hard  to  focus  on  anything  when  you’re  in  severe  pain.  (P  7)       Being  unable  to  trust  their  professional  caregivers  to  listen  to  them  undermined  the  women’s  resolve  and  motivation  to  speak.  The  women  indicated  that  when  they  were  unable  to  speak  about  their  feelings  and  preferences  they  used  a  passive    50 approach  to  their  labours  and  births.  They  lost  their  connections  to  their  bodies.  The  participants  also  described  professional  caregivers  coming  to  look  at  the  machines  in  their  birthing  rooms  without  speaking  to  them  which  made  them  feel  like  objects  rather  than  active  participants  who  were  engaged  in  their  labours  and  births.  One  woman  indicated  that  a  professional  caregiver  had  not  introduced  themselves  before  acting  on  her.  Some  participants  described  consenting  to  a  major  procedure,  like  an  epidural  insertion  or  an  emergency  caesarean  section,  where  professional  caregivers  would  begin  prepping  them  without  actually  explaining  what  they  were  doing.  When  participants  were  prodded  and  pulled  at  in  various  ways,  without  being  informed  about  what  was  happening,  they  viewed  their  caregivers  as  untrustworthy  and  undermining  their  efforts  to  express  personal  agency.      …The  admitting  nurse  was  there,  and  it  was  the  nurse  who  did  the  assessment  and  I  assume  she  was  a  nurse.  It’s  just  like  somebody  just  comes  in  and  like  woop,  [they  perform  a  vaginal  exam],  I  don’t…it  could  have  been  like,  if  somebody  in  scrubs  showed  up,  I  would  have  just  been  like  okay.  I  guess  you’re  going  to  [do  this  exam]  so  anyway  part  of  it  too  is  you’re  not  in  your  right  mind  either  to  like  be  asking  oh,  and  who  are  you?  (P  7)    One  woman  described  her  uncertainty  about  most  of  the  professional  caregivers’  procedures  and  activities  because  she  was  not  included  in  any  discussions  about  what  was  happening  to  her  fetus.  She  described  a  particular  moment  when  many  health  care  providers  were  staring  at  the  fetal  heart  rate  monitor  and  not  saying  anything.  Everyone  was  just  listening  to  the  drop  in  fetal  heart  rate  and  monitoring  the  situation  without  a  word.    The  digital  monitor  of  his  heart  rate  cuz  at  one  point  this  was  kind  of  a  weird  point,  the  OBGYN  and  staff  was  there  and  the  midwife  and  [nurse]  and  everybody.  Like  nothing  was  happening…Everyone  was  like  in  a  semi-­circle  and  everyone  looking  at  the  little  monitor  as  it  dropped  from  like,  100,  98,  95,  and    51 everyone  just  sort  of  watching,  and  I  remember  being  like,  I  don’t  think  this  is  good.  (P  9)       After  interactions  with  professional  caregivers  where  the  women  felt  dismissed  they  depicted  increased  feelings  of  mistrust,  which  contributed  to  their  feelings  of  fear  and  loss  of  control,  and  in  some  cases  anger.  For  example,  some  participants  described  professional  caregivers  disregarding  their  opinions,  telling  them  that  a  procedure  did  not  hurt  when  in  fact  it  did,  or  prescribing  activities  to  them  in  very  forceful  ways.  One  woman  gave  an  account  of  this:    She  gave  me  an  IV  in  my  hand,  and  sort  of  jabbed  me  a  little  bit  crooked  and  I  bled  and  said  ‘oh’  when  she  jabbed  me  and  she  was  like  it  doesn’t  hurt,  I’m  like  no  it  does  I’m  bleeding…  (P  15)       When  caregiver  team  members  asked  questions  in  leading  ways,  which  did  not  seem  directed  at  the  women’s  actual  experiences,  participants  felt  that  caregivers  were  making  assumptions.    In  other  words,  the  women  indicated  that  whatever  caregivers  thought  was  happening  was  accepted  as  true,  which  undermined  their  trust  in  their  providers  and  excluded  them  from  decision-­making.  Some  participants  stated  that  when  they  told  care  providers  that  their  epidurals  were  not  working  or  that  they  began  feeling  contractions  again  members  of  the  team  repeatedly  asked  them  to  retake  the  test  without  looking  for  a  problem  or  re-­assessing  the  epidural.  The  women  described  feeling  pressured  to  answer  questions  in  certain  ways  even  if  they  did  not  actually  think  that  the  answer  was  true.    If  they  remained  unsure  about  where  they  felt  the  cold  for  an  ice  sensation  test  or  if  their  epidurals  were  effective  they  indicated  that  their  uncertainty  was  dismissed.  Encounters  where  the  women  felt  caregivers  were  disconnected  from    52 their  experiences  decreased  the  women’s  feelings  of  trust,  increased  their  anxiety  and  fear,  and  interfered  with  their  abilities  to  engage  in  their  labours  and  births.    You  walk  through  the  two  front  doors  and  you  check  in  at  that  first  uh  counter  there  where…it  feels  like  such  a  casual  environment  and  you’re  like  whhhaaa  like  I’m  out  of  control  I’m  not  coping  I  am  not  doing  well  and  then  you  feel  so  ashamed  for  feeling  that  way.  (P  1)           The  women  linked  their  loss  of  trust  and  their  feelings  that  others  were  taking  control  to  a  failure  to  view  them  as  autonomous  human  beings  with  valid  opinions  and  preferences.  When  they  felt  disregarded  it  was  difficult  for  them  to  stay  engaged  with  their  labours  and  births,  and  the  participants  felt  fear  because  of  their  uncertainty.       The  women  expressed  feelings  of  mistrust  towards  their  professional  caregivers  when  they  regarded  their  caregivers  as  not  giving  clear  information  about  their  actions  or  types  of  assessments.  Although  participants  indicated  being  grateful  for  the  life-­saving  skills  of  their  professional  caregivers,  their  feelings  of  gratitude  were  tempered  by  feelings  of  loneliness  and  fear  based  on  their  lack  of  trust.  Their  feelings  were  engendered  by  the  failure  of  professionals  to  inform  them  about  the  rationale  for  clinical  interventions  or  assessments  and  to  share  decision-­making.  Some  participants  described  not  receiving  debriefing  about  the  details  about  emergencies.  They  questioned  whether  the  primary  care  provider  was  truly  dealing  with  an  emergency  or  if  they  were  acting  to  avoid  liabilities.  When  their  care  providers  failed  to  communicate  with  them  the  women  described  feeling  fearful,  disconnected  from  their  bodies,  and  disengaged  from  their  labours  and  births.    I  just  remember,  looking  around  and  everyone  was  busy  with  their  job,  they  whisked  the  baby  away  and  I  [remember]…not  knowing  if  I  wanted  my  husband  to  stay  with  me  or  to  go  with  the  baby,  because  they  had  to…  take  her  away  really  quickly…I  mean  she  was  only  five  feet  across  the  room…but  I  was  so  scared  in  that  time  and…no  one  was  walking  me  through  what  was    53 happening…it’s  just  such  a  surreal  experience,  you  just  had  a  baby,  um  and  then…it  gets  messy  and  I  felt  like  my  biggest  fear  was  coming  true…(P  10)    Participants  who  expressed  expectations  about  being  heard  and  made  a  part  of  their  labour  and  births  felt  helpless,  out  of  control,  and  dismissed  when  no  conversations  occurred  between  their  care  providers  and  them  about  plans  of  care  and  the  uncertain  circumstances  of  their  labours  and  births.  When  the  women  noticed  a  limited  amount  of  disclosure  from  professional  caregivers  about  possible  risks  or  dangerous  circumstances,  they  experienced  more  fear  of  the  unknown  and  lack  of  control  over  their  own  bodies  and  births  and  the  safety  of  their  unborn  babies.    So  yes,  lost,  lost…I  kind  of  just  gave  up.  Just  stopped  and  went  okay,  but  the  funny  thing  is  in  my  mind  she  said  let’s  give  you  an  epidural…At  that  point,  I  wasn’t  you  know  when  you’re  not  on  your  game  and  tired,  I  should  have  known  better.  And  I  remember  they  gave  me  the  epidural  and  laid  me  down  they  put  a  drip  in  my  arm  and  the  Pitocin  monitor  came  out  and  I  went…  [expresses  frustrations]  like  now  I’m  on  Pitocin…But  ya  it  was  a  place  where  I  didn’t  want  to  end  up.  (P  11)    When  the  women  described  their  experiences  of  hospital  birthing  environments  as  purely  clinical  and  producing  the  sense  that  the  women  in  labour  were  sick  or  in  need  of  some  kind  of  fix  from  medical  professionals  they  indicated  that  they  felt  less  trust,  less  at  ease,  and  more  anxious.  Some  participants  indicated  that  their  preferences  to  view  birth  as  a  healthy  event  rather  than  a  state  of  being  ill  or  a  situation  needing  to  be  fixed  might  be  ignored  by  caregivers  who  recommended  clinical  interventions  that  they  would  not  want  and  might  be  unnecessary.  They  reported  feeling  lack  of  trust  and  being  afraid  of  the  unknown.    When  obstetric  emergencies  occurred  and  the  women  did  not  receive  a  complete  explanation,  they  were  uncertain  about  what  was  happening,  or  sensed  that  something    54 dangerous  was  happening,  and  became  very  afraid.  In  many  cases,  the  women  described  feeling  lonely  and  abandoned  by  caregivers.  Such  circumstances  increased  participant’s  mistrust  toward  their  professional  caregivers.    I  know  that  the  OB  stuck  her  hand  inside  of  me  to  pull  the  placenta  out  but  she  never  told  [me]…  I  really  would  have  maybe  been  less  fearful  if  she  had  said  like…but  you  know  okay  I’m  just  going  to  stick  my  hand  in  and  get  this  out,  oh  look  I  got  it  out,  um  the  bleeding  slowing  down…just  walking  me  through.  (P  10)       When  the  women  felt  alone  with  no  sense  of  shared  decision-­making  and  power  they  described  feelings  of  being  outside  their  bodies,  losing  a  sense  of  themselves,  deep  feelings  of  fear,  and  a  disconnection  from  their  experiences.    All  of  those  feelings  contributed  to  them  disengaging  during  their  labours  and  births  in  hospital.    So  ya  I’d  say  that  was  a  pretty  scary  time  and  I  just  remember  there  was,  ya,  the  button  got  pressed,  lots  of  people  came  in,  no  one  was  kind  of  talking  to  my  husband  or  I  anymore,  um  and  ya  and  we  just  like  weren’t  sure  kind  of  how  serious  it  [was].  (P  12)         The  participants  who  lacked  involvement  in  joint  decision-­making  with  their  health  care  providers  had  limited  feelings  of  trust  toward  their  professional  caregivers.  They  indicated  their  doubts  that  their  personal  preferences  and  expectations  would  receive  consideration.  The  women  who  lacked  trust  were  more  likely  to  express  disappointment  that  their  professional  caregivers  would  not  validate  their  opinions  or  emotions.  They  lost  confidence  in  their  caregivers.    Participants  said  that  lack  of  confidence  contributed  to  their  uncertainty,  fear,  and  disengagement  from  their  labours  and  births.    4.3.5  Distractions  from  Labour     Many  of  the  participants  described  the  distracting  elements  of  the  hospital  environments  as  including  processes  of  registration,  admission  to  triage  and  their  labour    55 rooms,  and  occasional  transfers  between  spaces  (e.g.  from  the  labour  suite  to  the  operating  room  and  from  there  to  the  recovery  room).  It  was  distracting  for  some  participants  to  re-­orient  themselves  continually  to  new  spaces  in  foreign  environments  of  hospitals.  They  often  found  these  environments  more  distracting  than  their  home  environments.  In  some  cases,  unfamiliar  and  distracting  environments  created  a  sense  of  uncertainty,  which  contributed  to  the  women’s  feelings  of  fear  or  anxiety.    They  put  me  into  the  tub…I  felt  like  I’m  in  the  tub  and  everyone  is  just  staring  at  me,  I’m  like  this  is  not…where  am  I,  it’s  all  new,  and  bath,…new,  and  the  temperature  is  too  hot,  it’s  not  the  way  I  want  it,  everyone  is  looking  at  me  expectant  waiting  and  I  can’t  make  anything  happen  and  then  my  labour  stalled,  stopped  dead.  (P  11)    Some  participants  expected  that  the  spaces  and  rooms  in  the  hospital  birth  environments  would  be  foreign  to  them,  so  they  were  not  surprised  about  expending  effort  to  focus  on  settling  into  the  hospital  spaces  rather  than  their  labouring  bodies  when  they  entered  them.  However,  many  participants  who  found  the  environments  busy,  distracting,  and  lacking  in  privacy  viewed  their  birth  experiences  as  chaotic,  which  increased  their  uncertainty  and  loss  of  control.  Those  feelings  reduced  their  sense  of  connection  to  their  bodies  and  their  abilities  to  focus  inwardly.  Participants  who  found  their  environments  distracting  described  feeling  afraid  of  the  unknown.  They  wondered  whether  they  would  be  able  to  handle  labour  and  birth  because  they  were  feeling  disconnected  from  their  bodies  and  disengaged  from  their  labours.  The  women’s  thoughts  of  how  their  labours  were  not  meeting  their  expectations  of  being  intimate  and  tranquil  distracted  them.    It  just  and  then…  and  the  bathroom  was  open  like  it  had  an  obviously  for  ease  of  nursing  and  care.  But  it’s  like,  it’s  just  a  curtain  and  you  know,  like  you’re  so  beyond  it  you  feel  like  you,  you’re  so  engrossed  in  being  in  there.  So  you  don’t    56 think  about  saying  can  you  close  the  curtain  or  whatever?  Because  you  kind  of  want  their  help  but  at  the  same  time  as  a  first….if…if  I  would  have  another  baby  I  would  do  it  differently  I  think.  (P  11)         The  participants  linked  distractions  in  the  hospital  birth  environments  to  their  increased  feelings  of  panic  because  they  worried  that  they  would  not  be  able  to  cope  with  labour  after  losing  their  foci,  connections  to  their  bodies,  and  their  engagement  with  their  labours.  They  described  feeling  that  everything  was  out  of  their  control.  Under  those  circumstances,  the  women  became  fearful  about  possible  interventions  they  might  require  if  they  could  not  refocus  after  becoming  distracted.    They’re  starting  to  tell  me…[if  you]…don’t  get  this  baby  out  in  the  next  ten  minutes…we’re  going  to  have  an  OB  come  in…to  assess  and  like  we’re  going  to  have  to  use  forceps…And  I  didn’t  want  any  interventions  so  maybe  they  told  me  that  to  motivate  me…I  was  so  out  of  control  because  I  didn’t  know  when  to  push.  I  had  people  telling  me.  I  had  people  holding  my  legs.  I  had  no  idea  at  that  point.  I  was  starting  to  get  scared  like  the  baby  is  not  going  to  come  out  it’s  going  to  be  stuck  here  forever.  (P  1)       The  presence  of  strangers  distracted  some  of  the  participants.  They  described  coming  into  contact  with  bystanders  in  hospital  spaces  during  what  they  regarded  as  one  of  the  most  life  changing  and  ideally  intimate  experiences  of  their  lives.  The  women  indicated  that  being  in  the  presence  of  strangers  reduced  their  feelings  of  comfort  and  safety,  which  reduced  their  connections  to  their  bodies  and  their  abilities  to  stay  engaged  with  the  rhythms  of  their  labours.  “So  I…tried  to  stay  out  of  that  room  as  much  as  I  could  cuz  they  [unfamiliar  healthcare  providers]  couldn’t  fit  into  the  shower…um,  So  I  used  the  space,  [shower],  as  a  way  to  keep  them  out  as  much  as  I  could”  (P  1).     Many  participants  linked  the  lack  of  privacy  in  the  hospital  birth  environments  to  feeling  uneasy,  frustrated,  and  distracted  which  contributed  to  their  feelings  of  fear.  The  women  indicated  that  when  students  were  part  of  the  caregiver  team  but  not  really    57 introduced  to  them  they  regarded  students  as  distracting  strangers.  Some  participants  mentioned  that  being  distracted  by  other  women  vocalizing  in  labour.  In  one  case  a  woman  witnessed  the  delivery  of  a  baby  from  behind  the  next  curtain.  Witnessing  the  birth  resulted  in  her  first  impressions  of  the  hospital  space  as  being  distracting,  public,  and  not  intimate  which  produced  ambivalent  feelings.  She  had  curiosity  and  amazement  about  the  other  woman’s  birth  but  discomfort  because  the  woman  did  not  have  privacy.       In  the  situations  when  some  of  the  women  described  encountering  invasions  of  their  privacy  (e.g.  having  healthcare  professionals  present  for  vaginal  exams,  and  during  epidurals  being  inserted)  they  indicated  that  the  group  surrounding  them  did  not  have  familiarity  with  them  but  knew  a  lot  about  them.  That  combination  of  lack  of  familiarity  and  high  levels  of  knowledge  reduced  their  sense  of  intimacy.  They  linked  losing  intimacy  to  losing  their  connection  to  their  labouring  bodies  and  a  sense  of  control.  One  woman  described  the  distraction  from  a  patient  in  the  next  triage  bed  beside  her  taking  her  out  of  her  own  experience:    All  I  remember…I  remember  hearing  her  moaning  and  thinking  oh  god  that’s  going  to  be  me  because  hers’  were  a  lot  worse…she  was  screaming  obviously  she  was  about  to  have  a  baby,  and  I  remember  thinking  oh  my  god  that  is  what’s  coming.  Like  it’s  going  to  get  way  worse  than  where  I  am  now.  (P  11)      Encountering  clinical  equipment  throughout  the  hospital  spaces  and  on  the  walls  of  the  hospital  rooms  created  reduced  feelings  of  safety  for  some  of  the  women  who  had  anticipated  letting  their  labours  take  their  natural  courses.  The  visible  equipment  increased  their  fears  that  their  births  would  take  on  a  clinical  flavor  with  equipment  involved.  For  example,  one  woman  said:    We  did  a  hospital  tour  before  obviously  D  day.  And  it…and  it  heightened  my  fear.  it  just  became  very  real  and  it  became  uh  um…  the  the  tools  that  I  was  shown  that  were  to  be  used  at  my  disposal  um  like  the  bar  on  the  bed  and  the  bath  and    58 and  stuff  like  that  all  heightened  my  anxiety  towards  the  fear  that  I  was  going  to…ah  the  pain  that  I  was  going  to  experience  during  childbirth.  (P  3)    4.3.6  Personalized  Care     Participants  became  more  fearful  when  they  described  the  impersonal  care  being  given  in  hospital.  Impersonal  care  undermined  the  women’s  trust  in  their  care  providers,  engagement  in  shared  decision-­making,  ease  in  hospital  environments,  and  abilities  to  stay  connected  to  their  bodies  and  engaged  with  their  labours  and  births.    When  the  women  detected  an  impersonal  tone  in  the  courses  of  their  care,  they  described  feeling  less  engaged  with  their  labours  and  births  because  they  did  not  feel  comfortable  in  the  hospital  environment.  They  indicated  that  the  place  and  the  people  failed  to  regard  them  and  their  births  as  individual  and  special.  I  was  a  temporary  resident  and…the  staff  treated  you  that  way  because  the  next  person  was  going  to  come  in  after  you.  That’s  not  a  negative  comment  in  the  way  that  they  were  mean…but  it  would  be  very  hard  to  switch  that  mentality  off  as  a  caregiver.  Because  you’re  going  to  have  your  baby,  I’m  going  to  see  you  and  in  24  hours  I’m  going  to  be  back  here  in  exactly  same  room  with  somebody  else.  (P  11)       Under  the  conditions  where  the  participants  viewed  the  hospital  environments  and  birthing  rooms  as  impersonal  and  sterile  and  not  fitting  with  their  expectations  about  the  special  event  of  labour  and  birth  they  felt  ill  at  ease.  They  regarded  their  care  as  lacking  personalization.  For  example,  a  woman  described  this  setting  in  this  way:  Day  in  and  day  out  they’ve  done  it  for  years.  They’ve  seen  it  all.  They’ve  seen  the  tragedy.  They’ve  seen  the  joy.  They’ve  seen  everything  so  when  you  walk  in  so  you  know  you  are  just  kind  of  another  number  you’re  going  through  this  incredibly  life  changing  moment  [and]  they’re  at  work  doing  their  everyday.  (P  1)      59 When  some  participants  described  professional  caregivers  as  performing  assessments  and  tests,  without  orienting  them  to  the  test,  asking  permission,  identifying  themselves  during  the  procedure,  or  updating  them  on  the  results  or  outcomes  of  the  assessments  and  tests,  they  viewed  their  care  as  impersonal.  They  described  decreased  trust  in  their  professional  caregivers,  and  having  their  circumstances  feel  clinical,  decreasing  their  sense  of  control,  and  increasing  their  sense  of  disengagement  with  their  births  and  disconnection  to  their  bodies.       Participants  indicated  that  they  wanted  personalized  care  in  relation  to  their  choice  of  pain  management  treatments.  The  women  who  wanted  an  epidural  would  often  want  that  treatment  used  in  a  unique  way  that  suited  their  preferences.  For  example,  some  participants,  who  requested  and  received  an  epidural,  were  comforted  and  reassured  by  their  ability  to  rest  for  a  time  while  still  having  contractions.  Other  participants  wanted  to  use  the  epidural  to  take  the  edge  off  their  contraction  pain  while  they  walked  around,  and  moved  in  and  out  of  their  beds  to  labour  in  different  locations  and  positions.  Some  participants  viewed  their  lack  of  opportunity  to  choose  what  type  of  epidural  they  received  as  emblematic  of  lack  of  personalized  care.    I  remember  saying  is  this  going  to  be  a  walking  epidural?  [the  midwife]  was  like,  nope…I  think  maybe  that…There’s  this  game  of  deferral  so  the  midwife  might  have  said,…we’ll  see  if  we  can  get  you  one,  but  the  best  might  be…to  get  this  labour  moving  again,  which  she  knew  is  what  I  wanted…[and  that]  a  full  epidural…would  be  the  best,  but  she  said,  you  know  what  I’ll  defer  to  the  anesthesiologist…(P  11)         When  the  participants  felt  that  the  courses  of  their  care  were  impersonal  they  were  more  likely  to  feel  frightened,  disappointed,  disengaged,  and  to  have  a  lack  of  positive  anticipation  for  their  births  and  labours.      60 But  you’re  still  scared  of  the  unknown,  having  a  baby  is  going  into  the  unknown,  and  the  women  that  see  it  every  day,  the  doctors,  the  nurses,  the  admitting  people,  it’s  all  normal  to  them.  And  it’s  not  normal  to  the  patient,  and  that’s  a  hard  thing  I  think  that  they  might  forget  that  actually  she’s  really  scared  and  she’s  really  anxious,  and  she’s  afraid,  and  we  need  to  help  her  along  the  way.  (P  11)       Participants  mentioned  that  they  wanted  decisions  about  their  care  based  on  their  unique  cases,  rather  than  on  rules  and  regulations  or  on  particular  statistics.  Some  participants  mentioned  that  they  were  given  recommendations  from  professional  caregivers  that  were  based  on  population  statistics  which  they  found  undermined  their  sense  of  trust  and  their  views  about  the  personalization  of  their  care.  One  woman  described  a  conversation  that  she  had  with  her  primary  care  provider  about  when  to  begin  induction.    I  was  being  given  information  about  a  broad  swath  of  women  who  maybe  didn’t  have  prenatal  care,  or  um  you  know  48  year  olds,  and  14  year  olds.  You  know  I  very  much  wanted  to  get  information  about  what  would  be  a  recommendation  in  my  case  rather  than  this  is  our  standard  practice  we  want  you  to  do  it.  (P  15)       While  many  of  the  women  were  content  to  have  care  that  was  described  as  evidence-­based,  they  wanted  the  care  recommendations  they  were  receiving  about  labour  and  birth  to  be  personalized.  Some  participants  felt  that  just  using  evidence  did  not  take  into  account  their  personal  and  unique  circumstances.  They  described  reacting  to  these  types  of  interactions  with  staff  as  having  feelings  of  deep  fear  about  the  direction  of  events  they  experienced  from  the  care  providers’  interventions.  In  one  woman’s  case,  this  manifested  as  the  care  provider  physically  coaxing  her  to  move  from  the  triage  room  to  the  outside,  which  she  did  not  want  to  do.  This  woman  linked  the  care  provider’s  failure  to  see  how  her  circumstances  were  affecting  her  willingness  to  enact    61 evidenced-­based  labour  care  plans  to  a  lack  of  personalized  care  to  feeling  unsafe.  This  woman  said  that  she  felt  unsafe  when  the  following  events  occurred:    I  didn’t  feel  like  I  had  any  internal  resources  to  deal  with  the  pain.  I  had  no  break  between  the  contractions  and  so  that  made  it  worse  for  me  that  I  was  being  physically  coaxed  to  get  outside  and  so  I…  I  did  because  the  rational  part  of  me  that  was  left  knew  that  that  was  good  idea  to  get  movement.  Like  I  did  know  that  so  I,  I  did  it  but  not  without..  like  great  discomfort.  (P  1).      In  another  situation,  a  woman’s  husband  advocated  strongly  with  her  midwife  for  his  wife  to  stay  in  hospital.  His  advocacy  helped  this  woman  feel  secure,  because  of  her  fear  of  being  sent  home.  The  participant  pointed  out  that  her  increased  security  did  not  arise  from  an  opportunity  to  choose  her  time  of  admission  coming  from  professional  caregivers  but  from  a  personalized  approach  directed  by  her  advocate.    Some  participants  reacted  to  caregivers’  suggestions  that  appeared  to  lack  acknowledgement  of  their  individual  circumstances  by  presenting  a  helpless  plea  to  them.  Circumstances  where  professional  caregivers  failed  to  personalize  their  care  undermined  the  women’s  sense  of  control  and  agency.  “Well,  yes  please  I  do  want  to  stay.  I  don’t  think  I  can  do  that  car  ride  again”  (P  7).     Some  of  the  participants  described  the  failure  of  registration  and  admission  processes  in  the  hospitals  to  align  with  their  immediate  concerns  as  disrupting  their  sense  of  engagement  with  their  labours.  When  they  lost  touch  with  their  bodies  it  created  more  anxiety  and  unease.    They  indicated  that  all  of  the  admission  information  could  have  been  collected  during  the  prenatal  period  rather  than  at  the  time  of  admission  for  labour.  One  woman  indicated  that  forcibly  completing  the  same  paper  work  twice  during  different  outpatient  assessments  increased  her  frustration.  Her  contemplation  of  filling  this  paper  work  out  a  third  time  prevented  her  from  wanting  to    62 return  home  while  in  early  labour.  Lack  of  personalized  care  during  the  participants’  initial  intake  procedures  (e.g.  filling  out  paperwork  and  answering  questions  related  to  registration,  and  waiting  in  public  hallways  and  vestibules)  could  induce  fear.  Other  participants  linked  their  lack  of  personalized  care  during  admission  to  feeling  frustrated.  Many  participants  described  feeling  a  lack  of  freedom  and  power  to  act  in  the  ways  they  preferred  because  health  care  professionals  used  a  non-­personalized  and  risk-­oriented  approach  to  clinical  management  of  labour,  which  contributed  to  their  feelings  of  frustration,  uncertainty,  and  fear.     Caregivers  made  some  of  the  women  very  aware  of  the  guidelines  and  policies  they  expected  them  to  follow.  The  participants  gave  examples  of  these  as  being  charting  all  of  the  events  and  observations  associated  with  their  labours  and  births,  and  following  prescribed  frequencies  of  fetal  monitoring  and  other  assessments.  For  some  participants,  unquestioning  adherence  by  professional  caregivers  to  institutional  guidelines  and  policies  contributed  to  their  perspectives  about  a  lack  of  personalized  care  and  their  sense  of  powerlessness  to  act  during  their  labours.  Receiving  institutional  and  medically  recommended  monitoring  and  treatments  that  the  women  indicated  gave  them  no  personal  involvement  in  decision-­making  resulted  in  them  losing  trust  in  their  care  providers,  their  connections  to  their  bodies,  and  their  abilities  to  engage  with  their  labours  and  births  and  feeling  fearful  about  the  outcomes.      Participants  reported  other  instances  where  they  lost  their  freedom  to  choose  and  power  to  act  (e.g.  using  scented  lotions  and  taking  a  particular  position  during  labour)  due  to  the  directives  of  specific  professional  caregivers  who  failed  to  account  for  their  personal  situations.  These  circumstances  illustrated  how  the  women  felt  the    63 courses  of  their  care  were  sometimes  institution-­focused  rather  than  client-­focused.  Therefore,  they  perceived  limited  personalized  care  which  affected  their  abilities  to  engage  with  their  labours  and  births.     4.4  Summary   Participants  described  their  feelings  of  fear  during  their  hospital  birth  experiences  when  they  received  no  support  to  engage  in  their  labours  and  births.  Participants’  collective  perspectives  identified  experiences  in  which  they  often  did  not  receive  care  that  incorporated  teamwork  and  collaboration  with  them.  When  the  women’s  care  did  not  include  them  and  enable  them  to  act  as  active  participants  in  their  labours  and  births,  they  described  feeling  uneasy,  anxious,  and  fearful.  The  participants  who  were  fearful  were  unable  to  focus  during  their  labours  and  engage  with  their  labours  and  births  while  staying  connected  to  their  bodies.  Under  conditions  where  the  women  felt  disconnected  from  their  bodies,  excluded  from  decision-­making  processes,  restricted  in  their  use  of  hospital  space,  reduced  trust  towards  their  professional  caregivers,  distracted  from  their  labours  and  births  by  environmental  features,  and  in  receipt  of  impersonal  care,  they  reported  having  difficulties  engaging  with  their  labours  and  births  and  more  feelings  of  fear,  anxiety,  helplessness.  The  participants  had  a  lack  of  positive  anticipation  of  their  births  in  these  cases.      In  the  next  chapter,  I  place  my  findings  in  the  context  of  current  research  in  the  field  of  childbirth  fear,  refer  to  the  significance  and  contributions  of  my  thesis  research,  and  comment  on  the  strengths  and  limitations  of  my  research.  I  then  describe  the    64 nursing  implications  in  the  areas  of  practice,  administration,  education  and  research  that  arise  from  my  findings.            65 5:  Discussion  of  Findings,  and  Implications    5.1  Introduction     I  begin  this  chapter  with  a  summary  of  the  study  findings.  Following  this,  I  describe  how  the  study  findings  extend,  refute,  or  fit  with  current  literature  on  women’s  perceptions  of  hospital  birth  environments  and  their  influence  on  women’s  FOC.  I  also  make  recommendations  from  the  study  findings  for  clinical  practice,  education,  and  research.    5.2  Summary  of  Study     The  study  sample  comprised  fifteen  participants  who  had  given  birth  to  one  child  within  a  period  of  two  months  to  three  years  prior  to  participating  in  the  study.  Whether  the  women  had  the  opportunities  to  feel  engaged  with  their  births  influenced  their  feelings  of  comfort  or  fear  during  the  course  of  their  care  in  hospital  birthing  environments.       Many  of  the  participants  experienced  fear  and  difficulty  engaging  with  their  labours  and  births  due  to  factors  relating  to  the  hospital  birth  environments.    The  major  theme  capturing  the  data  was:  Women’s  engagement  with  their  labours  and  births.  The  theme  incorporated  six  sub-­themes:  Women’s  connections  to  their  bodies;;  women’s  inclusion  in  decision-­making  processes;;  freedom  to  use  the  hospital  space;;  feelings  of  trust  toward  professional  caregivers;;  distractions  from  labour;;  and  personalized  care.  When  the  participants  described  having  their  connections  to  their  bodies  (inward  focus)  disrupted,  being  left  out  of  decision-­making  processes  about  their  bodies  and  births,  being  distracted  from  their  labours  by  situations  around  them,  and  being  restricted  in  their  use  of  hospital  space,  they  experienced  more  fear  and  anxiety.  Erosions  in  their    66 feelings  of  trust  and  sense  of  personalized  care  contributed  to  their  fear,  helplessness,  discouragement,  and  loneliness.  The  women  described  a  failure  to  have  their  labour  and  birth  preferences  and  expectations  validated  by  their  care  providers,  and  control  over  the  events  and  activities  surrounding  their  labours  and  births  as  contributing  to  their  feelings  of  fear,  helplessness,  disappointment,  defeat,  discouragement,  loneliness  and  lack  of  positive  anticipation  for  their  births.    5.3  Discussion    The  study  participants  emphasized  their  sense  of  helplessness,  disappointment,  defeat,  discouragement,  loneliness,  and  fears  for  their  babies.  Many  of  these  feelings  are  captured  in  the  WDEQ  and  are  also  attributes  of  fear  of  childbirth  including  fear,  loneliness,  and  lack  of  positive  anticipation  for  their  birth  (Garthus-­Niegel  et  al.,  2011).  The  study  participants  described  those  attributes  when  they  experienced  barriers  to  being  engaged  in  their  labours  and  births.     The  study  participants  indicated  they  were  disconnected  from  their  bodies,  in  part  due  to  multiple  distractions,  restricted  in  their  use  of  hospital  space,  exposed  to  impersonal  care  and  excluded  from  decision-­making.    Those  experiences  contributed  to  mistrust  toward  caregivers  and  feelings  of  fear,  anxiety,  loneliness,  and  lack  of  positive  anticipation  for  their  births.  A  subset  of  these  women’s  feelings  are  reflected  in  subscale  factors  in  the  revised  version  of  the  Wijma  Delivery  Expectancy/Experience  Questionnaire  (WDEQ-­A)  (Pallant  et  al.,  2016).  The  WDEQ  had  been  viewed  as  a  unidimensional  tool,  which  limited  the  usefulness  of  the  tool  in  any  exploration  of  different  aspects  of  FOC  (Pallant  et  al.,  2016).  Research  conducted  by  Pallant  and  colleagues  in  2016  suggested  that  this  measure  is  best  operationalized  as  a    67 multidimensional  tool;;  the  authors  claimed  that  multidimensionality  increases  the  psychometric  soundness  of  the  tool  and  improves  inquiry  into  the  effects  of  FOC.  In  the  revised  version  (WDEQ-­A)  new  subscale  factors  included,  negative  emotions,  lack  of  positive  emotions,  social  isolation,  and  moment  of  birth  (Pallant,  et  al.,  2016).  My  thesis  work  supported  these  authors’  conclusions  that  exploring  differential  aspects  of  FOC  is  an  important  consideration  when  studying  FOC  because  participants  described  experiences  with  negative  emotions,  lack  of  positive  emotions,  and  feelings  of  social  isolation  (Pallant  et  al.,  2016).    Study  participants  also  referred  to  their  disconnection  from  the  actual  moment  of  their  births,  which  contributed  to  their  feelings  of  fear.    Study  participants  stated  that  under  conditions  in  which  they  received  impersonalized  care  they  became  disengaged  with  their  labours.  They  described  feeling  outside  of  themselves,  afraid,  and  uncertain  of  their  surroundings.  They  felt  a  loss  of  self  when  they  were  viewed  as  another  labour  statistic  rather  than  a  unique  woman  with  their  own  preferences  and  expectations  about  labour  and  birth.  Receiving  impersonal  care  contributed  to  their  loss  of  control,  uncertainty  and  mistrust  towards  their  caregivers  and  fear.  Current  literature  does  not  link  women’s  receipt  of  impersonalized  care  to  FOC;;  however,  researchers  have  described  women’s  needs  for  personalized,  trust  evoking,  and  collaborative  care  to  feel  safe  and  comfortable  during  their  labours  and  births  in  hospital  (Hall,  Tomkinson,  &  Klein,  2012).  My  study  findings  appear  to  support  previous  work  but  also  extend  knowledge  about  the  impacts  of  impersonal  care  on  women’s  feelings  of  fear  during  labour  and  birth.       My  study  participants  wanted  team-­based  care  that  focused  on  their  preferences,  with  them  at  the  center  of  the  team.  Without  that  kind  of  care,  they  had  difficulty    68 engaging  with  their  labours  and  births  and  remaining  connected  to  their  bodies.  The  participants’  expressed  preferences  fit  with  the  concept  of  shared  decision-­making.  Shared  decision-­making  has  been  defined  by  the  Institute  of  Medicine  as  being,  “A  partnership  among  practitioners,  patients,  and  their  families  (when  appropriate)  to  ensure  that  decisions  respect  patients’  wants,  needs,  and  preferences  and  that  patients  have  the  education  and  support  they  need  to  make  decisions  and  participate  in  their  own  care”  (Elwyn,  Edwards,  &  Thompson,  2016,  p.4).  My  participants’  preferences  also  fit  with  published  recommendations  for    professional  maternity  caregivers  to  provide  client-­focused  care  (BC  Perinatal  Health  Services,  2010)  and  compassionate  care  (Curtis,  Horton,  &  Smith,  2012)  as  stated  in  guidelines  by  various  local  and  international  nursing  and  health-­care  professional  governing  bodies  (Perinatal  Services  BC,  2010).    The  study  findings  suggest  that,  under  conditions  in  which  limited  shared  decision-­making  occurs,  women  feel  excluded,  which  can  contribute  to  their  negative  feelings  about  labour  and  birth,  namely  lack  of  positive  anticipation  for  their  births,  and  fear.  Patient  engagement  is  not  a  concept  that  has  received  extensive  attention  in  the  literature  relating  to  childbirth  fear.  My  study  participants’  emphasis  on  lack  of  teamwork  and  shared  decision-­making  extends  our  understanding  about  the  contribution  of  a  failure  to  work  in  teams  to  women’s  negative  feelings  and  fear  during  labour  and  birth.  The  necessity  for  shared  decision-­making  has  been  addressed  in  the  context    of  particular  elements  of  maternity  care,  such  as  position  during  second  stage  (Nieuwenhuijze,  Jonge,  Korstjens,  &  Lagro-­Jansse,  2012),  induction  of  labour  (Moore,  2016),  treatment  for  ruptured  membranes  (Beckmann,  Cooper,  &  Pocock,  2015),    and  elective  caesarean  sections  (Munro  et  al.,  2016).  The  previous  studies  have  explained    69 the  importance  of  women  receiving  support  to  make  well-­informed  decisions  that  are  consonant  with  their  values  and  ideals.  However,  the  previous  studies  did  not  link  women’s  fear  of  childbirth  to  instances  when  women  perceive  lack  of  shared  decision-­making  in  the  interactions  with  care  providers,  and  in  the  models  of  care  that  they  are  receiving.  The  women  who  participated  in  this  study  and  experienced  exclusion  from  decision-­making  felt  uncertain,  appraised  their  births  negatively,  and  felt  a  loss  of  control,  which  enhanced  their  fear  during  childbirth.    The  study  findings  indicate  that  women  regarded  professional  caregivers  as  often  lacking  consistency  in  their  care  and  expressed  a  need  for  client-­focused  care  for  all  parts  of  labour  and  birth.  The  findings  fit  with  research  about  key  elements  of  midwifery  care  that  contribute  to  women’s    perceptions  of  excellent  care  including:  Promoting  their  individuality;;  supporting  their  embodiment;;    going  with  the  flow,  and  receiving  information  and  guidance,  and  personalized,  shared  decision-­making  during  women  centred-­care  (Borrelli,  Spiby,  &  Walsh,  2016).  My  study  extends  our  understanding  of  the  importance  of  providing  women  with  these  elements  during  their  maternity  care  because  the  findings  illuminate  effects  of  impersonal  and  unwelcoming  care  practices,  women’s  exclusion  from  decision-­making,  and  sharing  limited  information  on  women’s  FOC.         My  study  findings  provide  North  American-­based  research  that  accesses  women’s  perceptions  about  how  hospital  birth  environments  contribute  to  fear  of  childbirth.  Only  three  international  studies  about  hospital  environments  and  childbirth  fear  were  located.  One  Iranian  study  (Taghizadeh  et  al.,  2015)  described  Iranian  women’s  discomfort  with  aspects  of  birth  environments  in  the  context  of  psychological    70 birth  trauma.  Taghizadeh  and  colleagues  (2015)  found  that  women  wanted  to  be  in  environments  that  were  more  relaxing  for  them,  allowed  them  to  have  a  birthing  partner,  and  provided  personalized  care. An  Iranian  study  investigated  mothers’  needs,  values,  and  preferences  during  normal  labour  and  birth  in  hospital;;  the  findings  highlighted  mothers’  fundamental  need  for  feeling  a  sense  of  control  and  empowerment  during  childbirth  (Iravani,  Zarean,  Janghorbani,  &  Bahrami,  2015).    The  participants  in  my  study  wanted  trust  and  collaboration  with  their  professional  caregivers  to  permit  engagement  with  their  labours  and  births,  which  lessened  their  fears  and  put  them  at  ease.  This  finding  is  similar  to  results  from  an  Iranian  study  where  women  who  had  their  informational  needs  met  during  their  labours  and  births  felt  a  sense  of  control  and  empowerment  during  their  labours  and  births  in  hospital  (Iravani  et  al.,  2015).       My  Canadian  participants  wanted  personalized  care,  and  relaxing  hospital  birth  environments  which  they  linked  to  reducing  their  anxiety  and  fear.  A  study  that  was  conducted  to  explore  first-­time  English  mothers’  expectations  for  a  good  midwife  identified  women’s  preferences  for  individualized  care,  with  midwives  providing  information  and  guidance  throughout  their  labours  and  births  (Borrelli  et  al.,  2016).      The  women  in  my  study  described  distractions  from  their  labours  and  births  when  labouring  and  birthing  in  hospital  environments.  They  regarded  elements  of  the  environment  as  not  reflecting  their  needs  during  labour  (e.g.  calm,  private,  and  intimate  environments).  Taghizadeh  and  colleagues’  (2015)  study  described  that  the  non-­human  environmental  factors  that  Iranian  women  described  as  terrifying  and  interfering  with  their  labours:  Hospital  rooms,  equipment,  and  procedures.  Study  participants  regarded    71 the  lack  of  explanation  about  the  presence  of  strangers,  and  clinical  equipment  and  procedures  contributed  to  them  feeling  uncertain,  ill  at  ease,  and  their  feelings  of  fear.       The  study  findings  highlighted  circumstances  where  the  women  thought  that  their  worst  fears  about  labour  and  birth  were  being  realized  during  their  intrapartum  hospital  stays.  When  study  participants  felt  threatened  by  events,  such  as  lack  of  shared  decision-­making,  lack  of  privacy,  and  impersonalized  interventions,  they  became  very  afraid  and  even  described  going  into  fight  or  flight  mode.  Other  literature  has  described  the  vicious  circle  of  fear  that  is  initiated  in  hospital  settings  when  women  feel  that  their  worst  fears  are  becoming  realized;;  the  stress  response  prolongs  labour,  causes  vasoconstriction  in  the  mother’s  circulatory  system,  reduces  placental  profusion,  and  has  negative  effects  on  labour  progress  and  fetal  wellbeing  (Stenglin  &  Foureur,  2013;;  Zar,  Wijma,  &  Wijma,  2001).  Conversely,  studies  have  suggested  that  some  women  find  available  medical  technology  a  comfort  because  technology  reduced  women’s  anxiety  during  labour  and  birth  (Goberna-­Tricas,  Banús-­Giménez,  &  Palacio-­Tauste,  2011).  The  women  in  the  study  describing  medical  technology  as  reassuring  may  not  have  experienced  circumstances  where  there  was  lack  of  shared  decision-­making  and  privacy,  and  imposed  impersonalized  interventions.    Some  of  study  participants  indicated  that  they  experienced  negative  effects  when  they  arrived  at  the  hospital  and  were  discouraged  from  admission  because  they  were  in  early  labour.  They  regarded  the  hospital  admission  procedures  as  rigid  and  failing  to  take  their  personal  experiences  into  account.  My  study  participants  also  identified  environmental  factors,  such  as  lack  of  communication  when  complications  arose  during  their  labours  and  births,  and  strangers  present  during  the  courses  of  their  labours  and    72 births  as  contributing  to  their  unease  and  childbirth  fear.  These  experiences  mirrored  other  accounts  of  women’s  experiences  of  labouring  in  hospital  environments  which  enhanced  their  childbirth  fear  (Bernhard  et  al.,  2014;;  Nyman  et  al.,  2011;;  Taghizadeh  et  al.,  2015).    5.4  Implications  for  Clinical  Practice     My  study  participants  identified  practices  and  interactions  with  their  professional  caregivers  that  inhibited  their  shared  decision-­making  and  engagement  in  their  labours  and  births.  In  what  follows,  I  outline  the  practice  strategies  that  I  have  developed  from  these  themes.   5.4.1  Women’s  Engagement  with  Their  Labours  and  Births     The  women’s  level  of  engagement  in  their  labours  and  birth  hinged  on  their  level  of  inclusion  which  has  implications  for  practice  arising  from  care  providers’  collaboration  with  patients  and  families.           Professional  caregivers  can  perform  report  for  transfer  of  care  in  the  presence  of  the  patient,  their  support  persons,  and  all  pertinent  caregivers.  Giving  women  options  to  choose  and  to  give  input  has  been  demonstrated  to  increase  patient  satisfaction  and  build  relationships  between  caregivers  (Anderson  &  Mangino,  2006).  Because  the  women  found  care  providers’  conversations  about  them  that  excluded  them  anxiety  and  fear  provoking  providers  can  eradicate  conversations  occurring  about  women  and  their  babies  that  only  incorporate  caregivers  in  the  presence  of  labouring  women.       When  planning  for  women’s  courses  of  care  behind  the  scenes  and  without  a  collaborative  approach  the  women  in  my  study  described  a  loss  of  control  for  them  and  their  families.  Caregivers  can  take  time  to  determine  women’s  and  families’  levels  of    73 knowledge  about  labour  and  birth  and  interventions  and  attend  to  women’s  needs  for  information  before  planning  courses  of  care.  Other  researchers  have  supported  that  approach  (Iravani  et  al.,  2015).    5.4.2  Women’s  Connection  to  Their  Bodies     The  participants’  connections  to  their  bodies  during  labour  and  birth  were  promoted  by  time  and  space  to  be  introspective  about  their  bodies.  Feeling  disconnected  from  their  bodies  made  the  women  afraid,  and  panicked.  The  women  regarded  forced  schedules,  and  activities  as  diminishing  calm  environments  for  their  introspection.  Caregivers  can  critically  reflect  about  their  regular  labour  and  birth-­related  time  sequence  plans  so  that  they  customize  the  care  schedules  and  activities  to  women’s  preferences  and  unique  needs.  Critical  reflection  requires  attention  to  women’s  feelings  and  methods  they  believe  will  promote  their  feelings  of  calm  and  control  of  their  own  bodies  and  mind.  Caregivers  can  bridge  the  disjunction  between  home  and  hospital  by  asking  women  about  what  type  of  strategies  were  working  well  at  home.    5.4.3  Women’s  Inclusion  in  Decision-­Making     Participants  indicated  that  inclusion  in  decision-­making  about  their  care  increased  their  sense  of  control  during  their  labours  and  births.  When  professional  caregivers  performed  independent  decision-­making  participants  felt  excluded  and  out  of  control  leading  to  fear.  Professional  caregivers  can  minimize  women’s  feelings  of  exclusion  and  fear  by  treating  informed  consent  as  a  complex  and  ongoing  component  of  patient  care.  They  can  use  the  guideline  for  maternity  care  pathway  (Perinatal  Services  BC,  2010)  to  assess  whether  appropriate  informed  consent  has  occurred.       74 5.4.4  Women’s  Freedom  to  use  the  Hospital  Space     Many  participants  described  the  importance  of  physical  action  to  move  through  the  rhythms  of  their  labours.  They  needed  the  hospital  space  to  move  freely  and  freedom  to  access  hospital  equipment  so  they  could  feel  in  control  and  focus  on  coping  with  their  labours.  Otherwise,  they  became  anxious  and  afraid  of  the  unknown,  whether  their  labours  would  progress,  or  whether  they  would  need  interventions  from  caregivers.       Professional  caregivers  can  get  involved  in  hospital  designs  that  make  waiting  rooms,  triage  rooms  and  bathrooms  more  suitable  for  women  in  labouring  positions.  Other  research  has  supported  limits  to  labouring  women’s  creative,  active,  and  self-­prescriptive  use  the  space  for  their  labours  because  there  are  inherent  limitations  in  the  design,  furnishings,  and  semiotics  of  hospital  environments  (Mondy,  Fenwick,  Leap,  &  Foureur,  2016).  Professional  staff  can  assist  labouring  women  to  play  an  active  role  in  their  labours  in  hospital  space.  Providing  women  with  opportunities  to  be  active  participants  in  their  labours  has  been  supported  by  other  research  (Ängeby,  Wilde-­Larsson,  Hildingsson,  &  Sandin-­Bojö,  2015;;  Borrelli  et  al.,  2016).      Study  participants  attributed  the  barriers  they  faced  in  feeling  relaxed  enough  to  be  engaged,  creative  about  their  use  of  space,  and  feeling  a  sense  of  ownership  of  the  hospital  space  to  care  providers’  emphasis  on  risk  management  procedures.  Other  research  has  implicated  procedures  founded  in  risk  management  principles  (i.e.  rigid  timelines  for  induction,  and  discouragement  of  flexible  fetal  heart  monitoring)  in  limiting    women’s  access  to  optimal  birth  spaces  (Seibold,  Licqurish,  Rolls,  &  Hopkins,  2010),  (i.e.    Other  strategies  could  be  for  caregivers  to  treat  the  use  of  equipment  and  interventions  as  a  shared  activity  with  women  engaged  in  choices.  Restructuring    75 admission  practices  to  ensure  a  consistent  welcoming  and  seamless  arrival  for  women  can  communicate  to  women  that  they  are  welcomed  guests  in  hospital  spaces.    5.4.5  Women’s  Trust  Toward  Professional  Caregivers     Participants  describing  lack  of  involvement  in  joint  decision-­making  with  their  health  care  providers  had  limited  feelings  of  trust  toward  their  professional  caregivers  because  personal  preferences  and  opinions  were  not  taken  into  consideration,  and  feelings  were  not  validated.  Lack  of  joint  decision-­making  could  lead  to  women  losing  confidence,  feeling  uncertain,  and  disengaging  from  their  labours  and  births,  culminating  in  fear,  as  the  women  in  my  study  pointed  out.  Health  care  professionals’  collaborative  approach  to  the  courses  of  care  can  enhance  women’s  trust  and  validation.   5.4.6  Distractions  from  Women’s  Labours  and  Births     Participants  linked  unfamiliar  equipment,  structures,  and  strangers  to  feeling  ill  at  ease,  distracting  from  their  inward  focus  during  labour,  and  increasing  feelings  of  insecurity,  and  fear.  Care  providers  can  take  time  to  acquaint  women  and  their  families  with  unfamiliar  elements  in  hospital  environments.  They  can  limit  women’s  exposure  to  strangers  by  attending  to  their  privacy  and  ensuring  that  any  new  arrivals  (care  providers)  introduce  themselves  and  spend  time  learning  about  the  women  they  encounter.  They  can  also  inform  women  proactively  about  who  they  might  be  meeting  while  in  labour  in  hospital  and  provide  simple  and  clear  explanations  prior  to  any  unfamiliar  experiences  or  interactions.       Professional  caregivers  can  guide  women  through  all  the  events  of  an  intrapartum  hospital  admission  by  explaining  procedures  and  caregivers’  regular  activities.  Those  actions  will  reduce  women’s  uncertainty.    Study  participants  indicated    76 that  they  wanted  some  preparation  prior  to  or  during  surprising  and  unfamiliar  circumstances  to  make  them  feel  included,  less  uncertain,  and  less  fearful  of  the  unknown.  Nursing  practice  that  reorients  women  to  their  internal  focus,  helps  them  feel  validated  in  their  abilities  to  cope  and  decreases  the  any  loss  of  control  and  feelings  of  uncertainty.  Helping  women  focus  enhances  their  feelings  of  certainty  about  their  labouring  bodies.  A  Scandinavian  study    in  home  birth  environments  supported  the  link  between  treating  women  as  the  center  of  attention  and  their  clear  sense  of  self  throughout  labours  and  births,  (Sjöblom,  Idvall,  &  Lindgren,  2014).   5.4.7  Personalized  Care   Study  participants  linked  caregivers’  use  of  assessments  and  tests,  without  orienting  them  to  the  test,  asking  permission,  identifying  themselves  during  the  procedure,  and  updating  them  on  the  results  or  outcomes  of  the  assessments  and  tests  to  impersonal  care  which  increased  their  sense  of  disengagement  and  disconnection  and  reduced  their  trust  in  caregivers.  Such  experiences  enhanced  the  women’s  fear.  All  care  providers  can  attend  carefully  to  women’s  expectations  and  experiences  so  that  they  can  provide  personalized  care.  The  positive  effects  of  women  receiving  personalized  care  is  supported  by  current  research  on  women’s    views  of  pillars  of  midwives’  good  care  practices,  which  is  attending  to  individuality  (Borrelli  et  al.,  2016).       Because  study  participants  described  their  desire  for  shared  decision-­making  and  personalized  and  collaborative  care  practices  health  care  providers  in  maternity  care  can  incorporate  principles  of  women-­centered  care  by  using  guidelines.  The  Maternity  Care  Enhancement  Project  (Province  of  British  Columbia,  2004)  recommended  care  practices  that  are  primarily  women-­centered,  collaborative,  and    77 team-­based  and  that  include  all  maternity  care  providers  (Province  of  British  Columbia,  2004).  Women-­centered  practice  initiatives  have  also  been  incorporated  in  the  latest  maternity  care  pathway  from  BC  Perinatal  Health  Program  (Perinatal  Services  BC,  2010).  5.5  Implications  for  Education   As  new  maternity  professionals  enter  the  field  they  are  at  risk  of  encountering  practice  realities  that  do  not  adhere  to  the  ideals  of  client-­centered  care  and  compassionate  caring  (Curtis  et  al.,  2012).  The  elements  that  seem  to  drive  the  values  and  in  turn  the  actions  of  some  care  providers  in  maternity  care  are  patient  safety  and  efficiency  of  labour  and  birth  rather  than  attending  to  women’s  personal  experiences  to  prevent  fear  and  promote  a  sense  of  security.  My  findings  support  the  link  between  women’s  subjective  experiences  of  their  birth  environments  and  their  FOC.  The  findings  of  this  study  indicate  that  all  practitioners  need  to  attend  to  a  culture  of  compassionate  practice.  Women  in  my  study  stated  that  they  encountered  medical  care  that  kept  them  free  of  complications  and  life  threatening  outcomes  but  that  did  not  instill  a  sense  of  teamwork  and  inclusion  during  their  intrapartum  experiences.  Previous  studies  have  suggested  differences  in  nurses’  and  physicians’  clinical  judgements  (Simpson,  James,  &  Knox,  2006).  The  differences  require  attention  in  professional  education  so  that  team  members  can  collaborate  on  safe  and  personalized  care.         Education  for  specialty  perinatal  nurses  entering  the  field  should  include  the  outcomes  associated  with  women’s  FOC.  There  is  a  high  prevalence  of  Canadian  women  experiencing  FOC  (about  one  quarter)  (Hall  et  al.,  2009)  and  the  women  in  my  study  have  stated  that  there  are  many  factors  contributing  to  their  feelings  of  fear  when    78 labouring  in  hospital  birth  environments.  Specialty  nurses  need  to  attend  to  women’s  experiences  and  attitudes  toward  labour  and  birth  in  order  to  better  understand  what  their  patients  would  find  reassuring  during  their  births  and  enable  women  to  stay  engaged.       Another  expectation  of  practice  for  registered  nurses  is  compassionate  practice  (Curtis  et  al.,  2012).  This  study  highlights  that  the  lack  of  personalized  care  which  undermines  compassionate  practice.  Nurses  and  other  care  providers  who  are  not  present  with  their  patients  and  listening  to  women’s  preferences  to  enhance  their  comfort  are  failing  to  provide  compassionate  practice  (Curtis  et  al.,  2012).       Perinatal  nursing  educators  need  to  impress  upon  those  they  teach  that  women’s  perceptions  of  hospital  birth  environments  influence  their  FOC.  This  is  because  a  culture  of  risk  management  and  therefore,  as  Seibold  et  al.  (2010)  described,  a  maternity  practice  influenced  by  caregiver  fear,  is  hindering  optimal  birth  environments  for  women  which  influences  their  fear  of  childbirth.  Furthermore,  students  can  benefit  from  awareness  of  negative  outcomes  arising    from  women’s  childbirth  fear  and  women’s  overall  perceptions  of  their  safety  and  their  baby’s  safety  in  hospital  (Melender,  2002).    CRNBC  standards  of  practice  indicate  that  nurses  are  to  uphold  client-­focused  provision  of  care,  specifically  nurses  are  to  communicate,  collaborate,  and  consult  with  clients  and  other  members  of  the  health  care  team  about  the  client’s  care  (College  of  Registered  Nurses  of  British  Columbia,  2005).  The  findings  from  this  study  indicate  the  negative  implications  of  women  being  excluded  in  conversations  about  their  care  or  having  students  ‘do  things  to  them’  without  adequate  introductions.  Nursing  instructors    79 can  work  with  students  and  regular  nursing  staff  to  ensure  that  students  have  proper  introductions  to  patients  and  seek  informed  consent  before  engaging  with  them.       One  outcome  that  requires  incorporation  in  specialty  courses  in  nursing  maternity  care  is  critical  inquiry  about  how  environments  foster  security  for  women.  It  is  beneficial  for  students  to  identify  challenges  arising  from  labour  and  delivery  contexts.  Case  study  teaching  about  patient  engagement  should  be  included  in  curriculums  with  opportunities  to  critically  inquire  about  the  practices  observed  during  clinical  practicums  in  perinatal  placements.    5.4  Implications  for  Research   The  study  findings  demonstrate  the  need  to  study  how  women  experience  childbirth  fear  in  different  cultural  settings.  They  raise  questions  about  the  applicability  of  the  WDEQ-­A  survey  in  clinical  settings  for  the  purposes  of  evaluating  the  emotional  health  of  women  facing  childbirth  and  identify  those  at  risk  of  FOC  (Pall  ant,  et  al.  2016).  My  study  illuminates  some  factors  at  play  with  regards  to  developing  fear  during  labour  and  birth  for  women.  Because  my  findings  suggested  that  shared  decision-­making,  women’s  connections  to  their  bodies,  and  limited  distractions  in  the  hospital  spaces  enhanced  women’s  outcomes  it  is  important  to  design  studies  that  address  barriers  or  challenges  for  professional  caregivers  attempting  to  institute  strategies  to  enable  women  to  engage  in  their  labours  and  births.  Study  designs  could  also  examine  institutional  structures  that  undermine  women’s  feelings  of  comfort  and  security  in  hospital  settings.       Research  studies  can  pose  questions  about  how  shared  decision-­making  is  being  operationalized  in  maternity  care  environments.  A  research  question  attends  to    80 professional  caregivers’  perceptions  about  women-­centered  care  and  mechanisms  for  its  practice.       My  study  findings  indicate  that  women  prefer  collaborative  maternity  care  with  attention  to  potential  emergencies  (e.g.  risk  management).  Further  research  should  focus  on  how  caregivers  might  integrate  rich  relational  practices  with  risk-­management  models.  A  research  question  could  be:  What  are  the  experiences  of  maternity  caregivers  in  enacting  shared  decision-­making  in  the  context  of  emergent  and  emergency  intrapartum  care?    5.5  Strengths  of  the  Study       The  women  in  this  study  had  experienced  a  variety  of  birth  experiences  and  were  very  motivated  to  tell  their  stories.  The  sample  of  women  I  interviewed  delivered  their  infants  in  different  hospital  locations  and  received  care  from  different  types  of  care  practitioners  (general  practitioners,  obstetricians,  and  midwives).  I  followed  principles  of  research  rigor  with  regards  to  reflexivity  and  data  confirmability  through  the  digitally  recorded  interviews  and  verbatim  transcription.  I  obtained  rich  descriptions  from  a  variety  of  cases  which  successfully  identified  women’s  perceptions  of  hospital  birthing  environments  and  the  influence  of  the  environments  on  women’s  feelings  of  fear.  My  supervisor  engaged  with  my  interview  data  and  assisted  with  data  analysis  which  reduced  researcher  bias  and  enhanced  transferability.    5.6  Limitations  of  Study       There  are  some  limitations  to  my  study.  The  participants  that  I  interviewed  all  came  from  a  fairly  homogenous  status,  for  example  they  had  higher  levels  of  education  and  household  incomes.  The  findings  lack  perspectives  from  women  who  are  exposed    81 to  higher  vulnerability  through  socio-­demographic  factors  and  other  determinants  of  health.  The  interviews  and  a  considerable  portion  of  the  data  analysis  rested  on  one  interpretation.  Although  the  women  experienced  a  variety  of  primary  care  providers  they  were  exposed  to  very  similar  hospital  practices  in  a  large  urban  Canadian  setting.  The  findings  are  not  generalizable  but  may  be  transferable  to  women  in  similar  settings.    5.7  Conclusion   FOC  is  an  important  phenomenon  in  our  society,  and  women’s  experiences  with  childbirth  and  their  attitudes  toward  modes  of  birth  influence  the  presence  or  absence  of  this  type  of  fear  in  both  men  and  women.  Limited  empirical  information  about  how  hospital  birth  environments  contribute  to  women’s  perceptions  of  their  FOC  restricts  evidence  available  to  professional  caregivers  so  that  they  can  reflect  on  their  practices  and  environments.  The  central  theme  from  the  findings  indicated  that  women  wanted  to  be  included,  engaged  and  connected  to  their  bodies  while  experiencing  labour  and  birth.  As  well,  despite  the  shortcomings  they  described,  many  women  wanted  to  experience  birth  and  labour  in  hospitals.  Even  in  highly  resourced  environments  Canadian  women  described  experiences  which  created  anxiety,  loneliness,  uncertainty,  and  fear.  These  women’s  experiences  of  labouring  and  giving  birth  in  many 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 in  nulliparous  and  parous  women.  Scandinavian  Journal  of  Behaviour  Therapy,  30(2),  75–84.       94 Appendix  A:  Recruitment  Letter           Recruitment  Letter  The  Influence  of  Environments  on  Fear  of  Childbirth  During  Women’s  Intrapartum  Hospital  Stays    My name is Jenny Auxier and I am a registered nurse and currently enrolled as a graduate student in the master of nursing program at UBC. I have worked in hospital as a labour and delivery nurse for 4 years. I am studying how women perceive their hospital birth environments by undertaking a research study about those environments and their potential effects on women’s feelings of reassurance or fear. To help this, I would like to recruit women who have delivered a child in the hospital at least two months ago. This study will be conducted through one-on-one interviews in a location chosen by you. The interviews will last between 40-90 minutes.  Criteria for participation:   •  Has given birth to their first child in hospital a minimum of two months ago, either vaginally or by cesarean section •  Has delivered in a hospital located in Vancouver or Richmond city area (does not have to reside in these cities to participate in this study)   If you would be interested in participating in my study on women’s perceptions of their hospital birth environments, please contact me by email or phone. If you would like to contact the Principal Investigator for any reason Dr. Wendy Hall can be contacted by email.      The	  University	  of	  British	  Columbia	  School	  of	  Nursing	  Vancouver	  Campus	  T201-­‐2211	  Wesbrook	  Mall	  Vancouver,	  BC	  Canada	  V6T	  2B5	  	  Phone	  	  604	  	  822	  7417	  Fax	  	  604	  822	  7466	  www.nursing.ubc.ca   95 Appendix  B:  Consent  Letter          Consent  Letter  The  Influence  of  Environments  on  Fear  of  Childbirth  During  Women’s  Intrapartum  Hospital  Stays   Principal  Investigator:  Dr.  Wendy  Hall,  UBC  School  of  Nursing   Co-­Investigator(s):  Jennifer  Auxier,  UBC  School  of  Nursing,  Master’s  in  Nursing  Student  (being  performed  for  my  graduate  degree)   Purpose: I  am  a  graduate  student  at  the  University  of  British  Columbia  School  of  Nursing  who  is  interested  in  examining  women’s  fear  about  childbirth.  Because  we  want  intrapartum  hospital  settings  to  facilitate  comfort  and  safety  for  all  women  in  labour  it  is  important  to  identify  the  environmental  factors  that  can  contribute  to  or  reduce  women's  childbirth  fear  during  their  hospital  stays.  If  we  have  more  information  about  women’s  experiences  changes  to  intrapartum  environments  that  can  increase  labouring  women’s  feelings  of  security  or  decrease  their  fear  responses  in  hospital  birthing  settings  will  be  more  possible.  Therefore,  my  research  question  is:  What  are  women’s  perceptions  of  the  influence  of  environments  on  FOC  during  intrapartum  hospital  stays?    I  am  inviting  you  to  take  part  in  my  research  study  because  you  have  recently  given  birth  to  your  first  child  in  a  local  hospital  environment.   Study  Procedures: Your  participation  in  the  study  will  involve  1.5  hours  of  your  time.  I  will  come  to  your  home  or  other  setting  you  might  choose  to  be  interviewed.  These  interviews  will  be  digitally  recorded  and  subsequently  transcribed  for  analysis.  The  transcribed  data  and  recorded  information  will  be  kept  in  files  on  an  encrypted  hard  drive  and  stored  in  a  locked  cupboard  in  the  principal  investigator's  (PI)  office  and  the  PI  will  be  the  only  individual  with  a  key  to  this  cupboard.  Any  technological  devices  that  are  used  to  perform  data  analysis  will  be  encrypted  and  pass  code  protected.  All  identifying  The	  University	  of	  British	  Columbia	  School	  of	  Nursing	  Vancouver	  Campus	  T201-­‐2211	  Wesbrook	  Mall	  Vancouver,	  BC	  Canada	  V6T	  2B5	  	  Phone	  	  604	  	  822	  7417	  Fax	  	  604	  822	  7466	  www.nursing.ubc.ca   96 elements  within  the  data  set  will  be  removed  and  pseudonyms  will  be  applied  to  preserve  confidentiality  for  participants. You  may  be  asked  to  provide  feedback  on  my  analysis  and  summary  of  the  themes  identified.  You  will  be  requested  to  answer  some  general  questions  after  the  interview  has  been  conducted  to  identify  some  brief  demographic  information.   Your  newborn  may  be  present  for  interviews  and  you  can  expect  the  interviews  to  last  between  40-­90  minutes.   Potential  Risks: If  you  feel  uncomfortable  at  any  time  during  the  interviews,  I  will  stop  the  recording  and  enable  some  time  to  talk  it  through.  Information  about  counselling  and  support  services  will  be  provided  for  you  to  access  independently  if  you  are  experiencing  overwhelming  negative  responses  to  study  questions.    Potential  Benefits: As  a  participant  in  this  study  you  will  have  the  opportunity  to  share  your  birth  experience.  You  might  benefit  from  sharing  detailed  information  about  your  birth  environment,  given  the  unique  experience  of  birth  and  the  power  of  sharing  your  story  with  a  research  professional.  It  is  expected  that  the  knowledge  gained  from  this  research  study  will  illuminate  both  supportive  elements  and  possible  barriers  to  providing  patient-­centered  care  in  maternity  hospital  settings.  I  will  send  you  a  summary  of  my  findings.  I  also  plan  to  disseminate  my  study  findings  to  parent  groups,  healthcare  professionals,  and  through  peer  reviewed  publication.  Confidentiality: Your  identity  will  be  kept  strictly  confidential  and  this  will  be  achieved  by  the  removal  of  all  individual  identification  information  from  transcribed  notes  and  all  other  research  files.  Although  your,  anonymity  will  be  ensured,  the  data  from  your  interview  will  be  incorporated  in  the  study  findings  which  will  be  published  in  a  peer-­reviewed  journal.    Contact  for  information  about  the  study: If,  at  any  time,  you  have  questions  about  procedures,  or  the  topic  of  study  please  feel  free  to  contact  the  researcher  Jenny  Auxier  or  the  supervising  faculty  Dr.  Wendy  Hall  by  email.    Contact  for  concerns  about  the  rights  of  research  subjects: If  you  have  any  concerns  about  your  treatment  or  rights  as  a  research  subject,  you  may  contact  the  Research  Subject  Information  Line  in  the  UBC  Office  of  Research  Services  at  604-­822-­8598  or  if  long  distance  e-­mail  to  RSIL@ors.ubc.ca.  Consent: Your  participation  in  this  study  is  entirely  voluntary  and  you  may  refuse  to  participate  or  withdraw  from  the  study  at  any  time  without  jeopardy  to  your  healthcare.     Your  signature  below  indicates  that  you  have  received  a  copy  of  this  consent  form  for  your  own  records.   97  Your  signature  indicates  that  you  consent  to  participate  in  this  study.         ____________________________________________________ Subject  Signature               Date  ____________________________________________________ Printed  Name  of  the  Subject  signing  above       98 Appendix  C:  Demographic  Questionnaire   Demographic Questionnaire  What is your age?  ___________________________  What was your mode of birth?  ___________________________  If you experienced labour did it begin spontaneously?   ___________________________  What is the gender of your child?  ___________________________  What is your child’s health status?  ___________________________  What is the highest level of education you have completed?  ___________________________  What is the yearly average income of your household? 20,000-34,999 35,000-49,999 50,000-74,999 75,000-89,999 ≥ 90,000  ___________________________  Do you live with a partner?  ___________________________  Are you employed outside the home?      99 Appendix  D:  Interview  Guide  Birth Environment Questions 1.  Remember  back  to  the  day  you  gave  birth,  what  were  your  memories  or  your  first  impression  when  you  were  in  the  hospital  environment.    2.  What  were  your  experiences  as  you  spent  time  during  your  labour  and  birth  in  hospital?      How  would  you  describe  the  effects  of  the  spaces  on  your  labour  and  birth  experience?    How  would  you  describe  the  effects  of  the  people  you  encountered  on  your  labour  and  birth  experience?    3.  Please  give  your  account  of  your  most  memorable  interactions  that  affected  your  labour  and  birth  experience  in  hospital.  What  made  these  interactions  memorable  for  you?      4.  What  would  you  say  were  some  of  the  important  events  during  your  hospital  stay?      5.  In  each  event:    How  did  those  events  affect  your  feelings  about  your  labour/birth  including  any  feelings  of  reassurance  and  comfort  or  fear?    Can  you  recall  any  memorable  sounds,  sights,  touches,  or  smells  during  your  labour  and  birth  experience  in  hospital?  How  did  those  elements  affect  your  labour/birth  experiences  including  any  enhanced  sense  of  fear  or  comfort?      Overall  how  did  the  hospital  birth  environment  affect  your  feelings  of  comfort/safety  during  your  birth  and  labour?      Overall  how  did  the  hospital  birth  environment  affect  your  feelings  of  fear/stress  during       your    birth  and  labour?                 100 Appendix  E:    Modified  Interview  Guide   Birth Environment Questions Remember  back  to  the  day  you  gave  birth,  what  were  your  memories  or  your  first  impression  when  you  were  in  the  hospital  environment.  (you  can  begin  from  when  you  were  having  labour  at  home  and  what  made  you  decide  you  were  going  to  come  into  hospital).      •  Did  you  enter  the  hospital  prior  to  arriving  during  your  intrapartum  stay,  did  you  attend  a  hospital  tour?      What  were  your  experiences  as  you  spent  time  during  your  labour  and  birth  in  hospital?    •  What  were  your  perceptions  of  the  events  that  led  to  the  progression  of  pain  management  plans,  or  of  labour  progression  plans?      •   If  an  emergency  moment  occurred,  what  was  decided  and  how  was  it  decided  upon,  what  were  the  effects  of  the  decisions  and  how  this  planning  occurred?      •  How  did  the  decision-­making  processes  influence  women’s  feelings  of  safety,  comfort,  or  fear?      How  would  you  describe  the  effects  of  the  spaces  on  your  labour  and  birth  experience?    How  would  you  describe  the  effects  of  the  people  you  encountered  on  your  labour  and  birth  experience?    Please  give  your  account  of  your  most  memorable  interactions  that  affected  your  labour  and  birth  experience  in  hospital.  What  made  these  interactions  memorable  for  you?    What  would  you  say  were  some  of  the  important  events  during  your  hospital  stay?      In  each  event:    How  did  those  events  affect  your  feelings  about  your  labour/birth  including  any  feelings  of  reassurance  and  comfort  or  fear?    Can  you  recall  any  memorable  sounds,  sights,  touches,  or  smells  during  your  labour  and  birth  experience  in  hospital?  How  did  those  elements  affect  your  labour/birth  experiences  including  any  enhanced  sense  of  fear  or  comfort?        101 Overall  how  did  the  hospital  birth  environment  affect  your  feelings  of  comfort/safety  during  your  birth  and  labour?      Overall  how  did  the  hospital  birth  environment  affect  your  feelings  of  fear/stress  during  your    birth  and  labour?        102 Appendix  F:  Second  Memo  Part  1     Introduction:       Women  in  our  study  describe  that  hospital  birth  environments  contribute  to  their  feelings  in  an  impactful  way  during  their  labours  and  births.  The  different  components  of  women’s  experiences  of  hospital  labours  and  births  that  are  contributing  factors  of  their  feelings  are  interactions  with  others,  foreign  and  unfamiliar  clinical  procedures  and  processes,  hospital  rooms  and  equipment,  women’s  expectations  influencing  their  feelings  of  affinity  with  their  birth  environments,  emergency  procedures  influencing  feelings  of  fear,  feelings  of  helplessness  resulting  from  times  of  uncertainty  and  loss  of  control,  and  times  of  uncertainty  influencing  feelings  of  fear.     Some  women  have  expressed  that  they  wanted  to  birth  in  hospitals  so  that  they  could  be  sure  they  would  be  medically  supported,  this  notion  gave  them  reassurance  for  their  own  safety  and  for  the  safety  of  their  babies  (IN4  ll859-­864;;  IN13  ll332-­334;;  IN12  ll653-­657).  Some  women  have  expressed  that  although  they  felt  medically  supported  in  their  births  and  labours  while  in  hospital  birth  environments  they  felt  that  in  the  hospital  birth  environments  they  were  faced  with  many  hindrances  in  their  abilities  to  create  the  birth  that  they  wanted  for  themselves,  and  this  left  some  of  the  women  feeling  helpless,  and  in  some  cases  fearful  (IN11  ll766-­769).     Some  women  have  explained  how  hospital  environments  produce,  for  them,  circumstances  and  events  that  contribute  to  ambivalent  feelings.  These  feelings  represent  women  having  a  sense  of  security  and  a  fear  of  the  unknown  at  the  same  time  while  experiencing  labour  and  birth  in  hospital  environments  (IN10  ll665-­668,  ll851-­855).  Some  women  explain  this  as  them  having  positive  feelings  of  security  knowing    103 that  medical  back  up  is  present  in  the  hospital  birth  environments  but  at  the  same  time  that  they  are  presented  with  many  environmental  factors  that  contribute  to  their  fears  of  the  unknown,  and  fears  that  are  brought  on  by  their  sense  of  loss  of  control  and  helplessness  in  the  intuitional,  medicalized  environments  of  hospital  birthing  spaces  (IN7  ll733-­756;;  IN15  176-­181,  730-­736;;  IN10  508-­519).     Although  some  women  in  the  study  experienced  these  conflicting  feelings  there  were  examples  of  women  feeling  that  they  had  empowering  births  in  hospital  (IN14  ll585-­592).  Some  women  stated  that  these  experiences  took  place  because  they  received  effective  and  comfortable  labour  support  from  hospital  staff  and  the  caregiver  teams  (inclusive  of  doctors,  specialists,  midwives,  and/or  nurses).  Some  women  stated  that  that  influenced  their  sense  of  control  over  their  own  abilities  to  create  the  birth  that  they  wanted  for  themselves,  which  gave  them  feelings  of  empowerment  and  comfort.  These  women  stated  that  in  the  event  that  they  felt  an  affinity  between  themselves  and  the  care  givers  that  they  were  reassured  and  also  experienced  agency  in  their  births  and  labours.  Some  women  stated  that  the  they  were  able  to  experience  agency  of  their  births  and  labours  in  part  due  to  positive  interactions  between  themselves  and  the  members  of  their  caregiver  teams.  Specifically,  some  women  were  reassured  in  their  ability  to  have  agency  in  their  births  when  members  of  the  caregiver  team  initiated  informative,  measured  conversations  with  them  about  any  uncertain  circumstances  that  arose  (i.e.  Lack  of  progress  in  labour,  or  abnormal  fetal  heart  rate  findings).       Some  women  in  our  study  have  described  how  the  hospital  environment  influences  their  ambivalent  feelings  and  their  feelings  of  fear  in  the  following  ways:        104 Interactions  with  Others     The  women  in  our  study  have  mentioned  how  interactions  with  hospital  staff,  their  support  persons,  and  others  have  greatly  influenced  their  feelings.  Women  in  our  study  have  described  that  some  interactions  that  they  had  with  others  while  entering  and  being  in  hospital  environments  during  their  births  and  labours  were  impactful  of  their  feelings  of  comfort  or  of  fear.  Women  encountered  many  others  while  in  hospital  and  this  really  is  a  striking  component  of  all  hospital  births  and  labour  experiences,  as  hospitals  are  public  spaces.  As  such  women  in  our  study  described  that  they  came  into  contact  with  many  members  of  the  public  in  hospital  spaces  and  this  is  all  while  they  were  undergoing  one  of  the  most  life  changing  (IN1  ll506-­513)  and,  ideally,  intimate  experiences  of  their  lives.  While  the  women  in  our  study  give  accounts  of  when  they  came  into  contact  with  members  of  the  public  they  of  course  are  were  interacting  with  hospital  staff  in  a  variety  of  ways  also.  The  nature  of  interactions  with  hospital  staff  is  very  stimulating  and  sometimes  fear  provoking  for  women  because  they  often  were  meeting  these  staff  for  the  first  time  and  often  were  speaking  to  these  strangers  while  experiencing  great  distress  and  low  energy  as  a  result  of  labour.       The  women  in  our  study  described  hospitals  as  public  spaces.  Women  in  our  study  mentioned  that  they  experienced  interactions  with  strangers  in  hospital  and  sometimes  this  was  very  distracting  and  at  times  fear  provoking.  Some  women  stated  that  they  witnessed  women  labouring  and  birthing  in  stalls  next  to  them  (IN11  ll49-­58;;  IN14  ll82-­93,  ll101-­104;;  IN7  ll38-­40)  during  their  initial  triage  experiences.  Others  stated  that  they  were  made  to  wait  in  hallways  with  other  patients  and  families  (IN13  ll75-­77),  and  in  one  case  a  women  waited  within  ear  shot  of  health  care  professionals  speaking    105 about  other  patients  in  detail  (IN5  ll67-­71).  Women  described  having  to  travel  in  elevators  and  through  hallways  which  left  them  at  times  feeling  very  exposed  to  strangers  and  also  on  occasion  hearing  others  (like  patient  visitors  or  hospital  porters)  talk  about  them  during  these  travels  but  not  be  able  or  willing  to  respond  giving  them  distracting  thoughts  and  feelings  making  it  hard  for  them  to  completely  relax  into  their  labours  or  emergent  circumstances  (e.g.  Transferring  for  an  Emergency  c-­section)  (IN8  ll225-­228;;  IN2  ll202-­207).  Other  women  mention  that  they  had  become  distracted  by  other  women  vocalizing  in  labour  (IN8  ll653-­675)  and  in  one  case  a  women  witnessed  the  delivery  of  a  baby  from  behind  the  next  curtain  (IN11  ll49-­58),  this  distracted  her,  and  made  her  anxious  but  also  filled  her  will  a  sense  of  amazement,  ultimately  resulting  in  her  first  impressions  of  the  hospital  spacing  promoting  ambivalent  feelings,  feelings  of  curiosity,  amazement  and  those  of  discomfort,  and  anxiety.       Women  in  our  study  gave  account  of  important  interactions  with  staff  that  influenced  their  feelings  of  fear  and  loss  of  control,  and  in  some  cases  anger.  (IN11  ll322-­332;;  IN15  ll108-­121;;  IN14  ll152-­157;;  IN7  ll491-­506).  Some  examples  of  these  experiences  are  that  staff  would  disregard  a  women’s  opinion,  tell  them  that  a  procedure  did  not  hurt  when  in  fact  it  did,  or  prescribe  activities  to  the  women  in  very  forceful  ways  (IN1  ll128-­139;;  IN15  ll114-­115).  Some  women  have  given  accounts  of  periods  where  members  of  their  care  provider  team  asked  them  questions  in  very  leading  ways  and  didn’t  seem  to  be  truly  inquiring  for  the  actual  experience  of  the  women  but  the  experience  that  the  health  care  provider  had  already  assumed  as  being  true,  for  example  when  some  women  stated  that  their  epidurals  were  not  working  or  that  they  began  feeling  contractions  again  some  members  of  the  team  repeatedly  asked    106 them  to  re  take  the  test  without  trouble  shooting  or  re-­assessing  the  epidural  itself  (IN11  ll409-­431).  Some  of  the  women  in  our  study  told  us  that  they  felt  pressured  to  answer  in  certain  ways  even  if  they  really  didn’t  think  that  was  true  or  if  they  remained  unsure  about  where  they  felt  the  cold  or  if  they  were  experiencing  effective  treatment  with  the  epidurals  (IN10  ll846-­858).    Foreign  and  the  Unfamiliar  Clinical  Procedures  and  Processes     Women  in  our  study  have  expressed  that  they  encountered  unfamiliar  procedures  being  performed  around  them  during  their  labours  and  births  in  hospital.  Some  women  mentioned  that  there  were  elements  of  this  care  model  that  were  seen  as  impersonal  and  inefficient  to  them  (IN13  ll18-­20).  This  foreign  and  unfamiliar  environment  struck  many  women  as  being  uncomfortable  and  in  some  cases  fear  provoking  (IN5  ll94-­112;;  IN6  ll136-­144).  Some  women  found  that  many  elements  of  the  medical  model  of  care  for  birth  and  labour.  Some  examples  women  gave  of  these  types  of  procedures  were,  the  registration  and  waiting  processes,  invasive  procedures,  members  of  the  care  team  wearing  face  masks,  having  students  providing  care  without  full  informed  consent  given  by  women,  allocation  of  room  assignments  for  patients,  and  the  restriction  of  movement  in  cases  of  emergency  C-­sections,  instrumental  deliveries,  or  because  of  the  use  of  an  epidural  (IN1  ll276-­280;;  IN2  ll555-­560;;  IN8  ll163-­169;;  IN7  ll384-­389;;  IN12  ll187-­202;;  IN11  ll375-­391,  397-­406;;  IN10  ll536-­549;;  640-­646)  Overall  the  women  in  our  study  explained  that  some  of  the  processes  and  procedures  of  the  medical  model  of  care  for  labour  and  birth  were  something  that  confused  them  at  times  and  hindered  them  in  their  abilities  to  create  a  relaxed  and  calm  atmosphere  for  their  labours  and  births.      107      The  various  examples  of  procedures  and  processes  that  the  women  in  our  study  described  gave  many  of  them  feelings  of  being  put  off,  and  unsettled  in  the  hospital  birth  environments.  One  woman  explained  that  she  got  an  unsettling  feeling  at  one  point  and  that  shortly  after  this  her  labour,  which  had  been  intensifying  while  at  home  now  stopped  (IN11  ll204-­210).  This  woman  stated  that  this  happened  after  she  spent  sometime  in  the  triage  area  witnessing  a  birth,  being  made  to  wait  to  be  assigned  to  her  room  and  her  nurse  which  was  a  confusing  and  chaotic  process  and  being  in  a  room,  in  the  tub  with  no  real  feeling  of  being  this  being  an  intimate  process  with  everyone  standing  around  staring  at  her,  having  a  sense  that  people  would  just  come  and  go  as  the  bathroom  had  only  a  curtain  to  enclose  her  (IN11  ll133-­178,  181-­195).         Women  in  our  study  have  a  variety  of  different  approaches  to  participating  in  their  care  during  labour  and  birth  in  hospital.  Many  of  the  components  to  labour  and  birth  are  foreign  to  new  mothers  and  the  hospital  procedures  can  be  hard  for  women  to  understand.  Women  vary  in  their  desire  to  understand  the  details  of  the  medical  model  of  care  for  labour  and  birth.  At  some  point  all  of  the  women  in  our  study  contemplated  a  limit  to  what  was  under  their  own  understanding  and  abilities  when  it  came  to  their  labours  and  births.  For  example,  some  women  felt  that  the  induction  of  their  births  and  decisions  how  to  manage  lack  of  progress  of  labour  was  something  they  could  be  given  information  about  and  make  informed  decisions  about  while  other  women  felt  that  these  matters  were  best  understood  and  prescribed  by  their  health  care  team.  One  woman  explained  that  she  found  the  many  options  and  suggestions  from  staff  and  their  explicit  attitude  of  team  work  with  her  throughout  her  labour  in  hospital  gave  her  confidence  and    108 security  during  her  labour  and  birth  in  hospital  even  though  she  was  immersed  in  an  unfamiliar  environment  the  team  of  care  providers  at  the  hospital  communicated  with  her  in  a  very  measured  and  accommodating  way  which  put  her  at  ease  throughout  many  strange  and  unfamiliar  experiences  like  in  the  case  when  the  OB  had  to  manually  rotate  the  baby’s  head  without  her  having  an  epidural.  Because  the  team  gave  her  options  she  felt  secure  enough  to  take  the  option  that  involved  less  interventions  (IN12  ll250-­269).         Whether  women  felt  they  had  a  good  understanding  of  the  medical  procedures  and  processes  for  the  management  of  labour  these  were  sometimes  unsettling  experiences  that  became  distractions  for  these  women.  What  appears  to  develop  in  each  woman’s  story  is  that  in  all  these  cases  the  distractions  prevented  the  women  in  focusing  inwardly  feeling  that  they  cannot  effectively  do  the  “job”  they  have  to  do  and  this  can  lead  to  panic,  or  fear  of  failure,  of  the  unknown,  and  of  possible  further  scary  interventions.             109 Appendix  G:  Second  Memo  Part  2    Hospital  Rooms  and  Equipment  Some  women  stated  that  the  hospital  environment  and  birthing  rooms  did  not  seem  set  up  for  the  special  event  of  labour  and  birth.  This  fact  left  them  feeling  not  at  ease,  because  they  got  a  sense  that  their  birth  was  nothing  special  in  this  context  of  care.  For  example,  one  woman  states  that  the  hospital  is  a  place  where  the  space,  does  not  belong  to  her,  that  many  women  have  come  before  to  birth  in  this  room  and  others  will  quickly  trickle  in  after  her  (IN11  ll689-­695)  that  this  is  just  the  everyday  occurrence  here  in  the  hospital.  Another  woman  states  that  the  space  surprised  her,  how  clinical  it  looked,  not  like  a  bedroom,  not  special  and  comforting  like  she  had  imagined  birth  spaces  should  be  like  (IN2  ll159-­169).  This  institutional  feel  that  some  women  speak  about  has  put  some  women  off  their  game  so  to  speak,  and  puts  doubts  into  their  minds  about  how  they  might  be  considered  just  another  tick  box  (as  one  woman  mentioned)  (IN13  ll92-­93)  on  the  hospital  staff’s  list  of  people  to  care  for,  rather  than  an  important  and  unique  mother  giving  birth  to  a  special  child.  This  is  an  example  of  how  women’s  feelings  of  positive  anticipation,  an  important  component  in  women  feeling  comfort  during  labour  and  birth,  is  influenced  by  hospital  birth  environments.  Some  women  in  our  study  describe  how  they  become  un-­inspired  during  their  births  due  to  some  underwhelming  relatives  of  the  physical  space  and  attitudes  of  the  staff  they  meet  and  this  makes  them  question  whether  their  experience  can  and  will  be  a  truly  special  and  positive  one.       While  the  women  in  our  study  felt  that  the  hospital  space  was  not  always  set  up  in  a  way  that  gave  them  a  sense  of  positive  anticipation  they  also  mentioned  many    110 examples  of  how  they  either  felt  freedom  to  utilize  the  space  or  not.  And  this  feeling  of  freedom  within  the  space  seemed  to  be,  for  many  of  the  women  in  our  study,  an  influencing  factor  in  their  ability  to  feel  secure  in  their  ability  to  do  their  job  in  labour.  So  what  mattered  to  the  women  was  that  the  work  of  labour  and  birth  was  accomplished,  some  women  really  wanted  this  work  to  be  in  their  hands,  others  preferred  to  leave  most  of  the  work  up  to  the  staff  in  hospital.  Some  women  mentioned  that  they  value  that  the  hospital  was  set  up  to  do  a  job  and  it  did  its  job  for  them  (IN14  ll630-­634;;  IN12  ll443-­453;;  IN13  ll525-­535;;  IN5  ll554-­557).  The  ways  that  some  women  felt  secure  was  that  the  hospital  was  equipped  with  the  supplies  and  instruments  required  for  birth  and  labour  (laughing  gas,  extra  towels,  basins,  clinical  monitoring  tools  etc.).  Other  women  mention  that  they  actually  were  able  to  use  the  beds  and  birthing  balls  and  laughing  gas  in  a  way  that  completely  supported  them  in  doing  the  work  of  their  labours.  One  woman  stated  that  she  was  so  tired  from  standing  up  with  every  contraction  while  labouring  at  home  that  to  be  able  to  lay  down  on  the  hospital  bed  and  use  the  laughing  gas  for  the  rest  of  her  labour  was  a  really  helpful  way  for  her  to  focus  inwardly  and  feel  powerful  enough  to  get  through  the  contractions  (IN6  ll80-­89).  Although  this  woman  did  find  it  very  fear  provoking  when  the  laughing  gas  tanks  became  empty  and  when  the  care  provider  team  took  the  gas  away  when  it  was  time  for  her  to  push  (IN6  ll316-­326).    Women’s  Expectations  Influencing  Their  Feelings  of  Affinity  Towards  Hospital  Birth  Environments       Some  women  who  have  experienced  events  not  as  their  expectations  had  prepared  them  for  and  this  produces  a  variety  of  emotions  depending  on  the  specific  expectations  and  standards  each  woman  had  for  their  labours  and  births.      111      Women  in  our  study  have  reflected  on  their  experiences  of  the  local  hospital  birthing  environments  as  clinical,  and  producing  of  a  feeling  that  when  you  enter  them  that  you  are  somehow  sick  or  in  need  of  some  kind  of  fixing  from  medical  professionals  (IN15  ll360-­365).  Some  women,  from  our  study,  have  explained  that  they  have  their  very  own  personalized  standards  for  birth  and  labour  that  sometimes  include  being  surrounded  by  the  clinical  expertise  of  the  staff,  although  many  of  these  very  same  women  stated  that  they  preferred  not  to  view  birth  as  a  state  of  being  ill  or  needing  to  be  fixed  (IN4  ll569-­572).  The  women  in  our  study  explained  that  they  value  having  the  back  up  of  hospital  staff  and  technologies  in  cases  of  extreme  risky  and/or  life  or  death  situations  (IN4  ll859-­864,  IN9  ll929-­933).         All  of  the  women  in  our  study  noted  that  they  were  grateful  for  the  lifesaving  and/or  important  work  that  hospital  staff  did  for  them  while  they  were  birthing  and  labouring  in  hospital.  Some  women  mentioned  that  they  do  however,  hold  some  ambivalence  toward  wanting  to  have  their  births  in  hospital  for  reasons  of  feeling  secure  medically  and  yet  finding  that  they  were  made  to  feel  helpless  in  some  cases  due  to  the  risk-­oriented  and  medical  management  of  labour  that  comes  from  having  medical  professionals  and  clinical  procedures  lead  the  courses  of  their  care  (IN10  ll851-­855).  After  interviewing  a  variety  of  women  it  is  important  to  note  that  some  women  in  our  study  experienced  very  clinical  procedures  that  influenced  their  feelings  of  helplessness  even  if  they  were  under  the  care  of  a  midwife  in  hospital.       Women  in  our  study  have  presented  a  variety  of  ideals  about  the  medicalization  of  birth  and  the  institutional  style  of  care  of  hospital  birth  environments.  Some  women    112 state  that  they  preferred  to  labour  as  naturally  as  possible  with  minimal  interventions.  Others  stated  that  they  wanted  to  make  use  of  all  the  drugs  for  a  labour  that  would  be  as  pain  free  as  possible.  And  others  put  the  most  emphasis  on  having  their  care  be  provided  in  a  way  that  was  personalized  to  their  unique  situations  and  that  their  support  system  and  care  givers  would  work  with  them  and  offer  them  suggestions  on  how  to  move  along  with  uncertain  circumstances  that  might  come  up  during  labour  and  birth.       What  we  found  is  that  all  of  the  women  hoped  to  have  an  affinity  with  their  care  giver  and  wanted  to  receive  a  care  model  that  suited  their  birth  attitudes.  What  has  evolved  from  the  narratives  is  that  every  woman  in  our  study  had  a  reaction,  either  positive  or  negative  depending  on  whether  they  felt  this  affinity  to  the  care  givers  and  well  aligned  care  models  to  their  own  attitudes  of  birth.  For  example,  some  women  in  the  study  expressed  that  they  had  an  expectation  for  feeling  safe  in  the  case  of  an  emergency  during  their  births  in  hospital,  and  when  emergency  did  strike  in  some  cases  these  women  were  reassured  by  the  efficiency  and  speed  of  the  care  providers  to  deliver  their  babies  safety  with  no  ill  effects  or  poor  outcomes  (IN2  ll259-­262;;  IN15  ll574-­587).  As  well,  some  women  expressed  that  they  had  expected  to  feel  listened  to  and  be  made  a  part  of  their  labour  and  births  were  left  feeling  helpless,  out  of  control,  and  left  out  when  they  were  not  spoken  to  directly  about  plans  of  care  and  uncertain  circumstances  of  their  labours  and  births  (IN15  ll140-­143).  For  example,  some  women  noticed  a  limited  amount  of  disclosure  from  medical  staff  about  possible  risks  or  dangerous  circumstance  and  this  gave  the  women  feelings  of  fear  of  the  unknown  and  lack  of  control  over  their  own  bodies  and  the  safety  of  their  unborn  babies  (IN10  ll387-­393).      113    Women  in  our  study  received  information  about  birth  and  labour  from  others  and/or  labour  and  birth  informational  resources.  This  information  prepared  them  with  a  variety  of  interesting  expectations  about  their  own  birth  and  labours.  One  common  topic  that  came  up  for  some  of  our  participants  was  the  hope  and  possibility  of  a  virtually  pain  free  labour  and  birth.  Some  women  had  been  told  exuberantly  by  others  to  “Get  the  epidural,  whatever  you  do,  get  the  epidural”  (IN9  ll240)  other  women  had  heard  that  using  the  laughing  gas  could  be  something  that  takes  enough  of  the  edge  off  that  you  could  use  it  for  the  entire  labour  (IN6  ll506-­511)  and  not  need  anything  else  the  entire  time.  Others  still,  looked  to  the  possibility  of  being  able  to  move  through  each  contraction  as  if  it  was  a  wave  or  lap  and  just  work  through  the  ebbs  and  flows  with  breathing  and  water  therapies  and  not  becoming  distracted  from  their  inward  focusing  (IN4  ll565-­586).     In  each  unique  case  the  women  all  expressed  that  they  were  influenced  emotionally  whether  their  expectations  for  their  labour  were  met  or  not.  Women  who  were  able  to  stay  in  their  zone  or  inward  focus  felt  reassurance  because  they  were  able  to  progress  in  labour  while  doing  what  they  had  hoped  to  do.  And  when  these  women  were  given  words  of  positive  affirmation  and  updates  about  their  labour  progress  this  increased  the  feelings  of  reassurance.  Women  who  got  the  opportunity  to  receive  an  epidural  at  their  request  when  they  felt  it  was  the  right  time  to  implement  this  intervention  were  comforted  and  reassured  with  their  ability  to  rest  for  a  time  while  still  having  contractions  (IN2,  IN3,  IN10  IN13,  IN15)       One  woman  who  had  hoped  for  a  break  in  contractions  and  wanted  to  build  some  seclusion  around  herself  was  repeatedly  told  by  the  majority  of  her  mixed  group  of    114 caregivers  (inclusive  of  midwives,  nurses,  and  doctors)  that  she  was  suffering  and  that  she  needed  an  epidural,  this  provoked  feelings  of  frustration  and  fear  for  this  woman  during  her  labour  and  birth  (IN1).  As  well,  some  women  experienced  having  surprising  procedures  or  events  occur  without  their  consent  and  in  some  cases  without  debriefing  after  the  fact  and  this  left  women  feeling  out  of  control,  helpless,  and  fearful  (IN9,  IN11).    In  either  case  whether  women’s  labour  and  birth  expectations  were  met  or  not  left  them  with  either  feelings  of  affinity  with  the  care  context  and  providers  or  feelings  of  inequality  with  care  providers  and  themselves.  When  women  felt  a  sense  of  affinity  with  care  providers  this  gave  them  a  sense  of  security  and  comfort.  When  they  did  not  have  these  feelings  of  affinity  with  the  care  context  and  providers  they  felt  unsettled  and  distracted  from  their  focus,  and  in  many  cases  very  fearful.    Emergency  Procedures  Influencing  Feelings  of  Fear     Some  women  experienced  certain  obstetric  emergencies  while  in  hospital.  Some  women  in  our  study  who  mentioned  that  they  experienced  an  emergency  during  their  care  in  hospital  felt  more  secure  in  these  moments  when  one  person  who  was  an  expert  completely  explained  everything  to  them  as  it  was  happening  (IN1,  IN10).  In  some  of  the  cases  for  the  women  in  our  study  who  experienced  emergencies  this  did  not  happen.  In  the  cases  where  women  in  our  study  did  not  know  what  was  going  on  entirely  but  did  know  that  something  dangerous  was  happening  they  became  very  afraid,  and  in  many  cases  felt  really  lonely  and  abandoned  by  caregivers  (IN11,  IN7,  IN15,  IN9,  IN10,  IN8).       Some  women  said  that  they  have  ambivalent  feelings  about  the  emergency  circumstances,  these  women  said  they  were  grateful  for  the  life-­saving  skills  and    115 resources  that  the  hospital  offered  but  that  they  find  it  impactful  that  they  were  left  feeling  lonely  and  frightened  during  these  times.  Some  women  did  not  receive  debriefing  about  the  details  of  the  emergency  situation,  even  to  the  point  where  they  are  not  entirely  sure  that  the  primary  care  provider  was  truly  dealing  with  an  emergency  or  if  they  were  acting  to  avoid  liabilities  (IN7,  IN15).    Helplessness  Feelings  Resulting  from  Times  of  Uncertainty  and  Loss  of  Control     When  any  feelings  of  helplessness  and  loss  of  control  occur  when  they  get  a  sense  that  all  the  actions  and  work  of  their  own  labour  or  birth  become  work  that  they  cannot  or  don’t  feel  they  have  been  invited  to  take  part  in  but  that  is  being  done  to  them  with  implied  consent.       Women  in  labour  are  inherently  going  to  feel  helpless  at  various  times  during  their  labours.  What  some  women  in  our  study  have  highlighted  through  the  telling  of  certain  events  is  that  the  hospital  birth  environment  contributes  to  another  layer  of  helplessness  that  is  externally  produced.  Some  women  have  discussed  how  some  conditions  of  their  births  in  hospital  contributed  to  them  feeling  powerful  and  in  control  during  their  labours  and  births.  For  example,  having  a  button  to  control  the  strength  of  the  sensation  they  felt  from  contractions  (IN10  ll240-­246).  Some  women  in  our  study  have  suggested  that  the  hospital  environment,  inclusive  of  interactions,  physical  space,  and  clinical  procedures  and  processes  has  the  influence  to  either  promote  empowerment  during  their  births  or  contribute  feelings  of  helplessness  during  their  birth  and  labours  which  in  some  women’s  cases  made  them  very  afraid.             116 Times  of  Uncertainty  Influencing  Feelings  of  Fear         Uncertain  circumstances  are  inherent  in  all  labour  experiences.  Women  in  our  study  who  birthed  and  labored  in  hospital  have  given  accounts  of  how  uncertainty  was  enhanced  by  the  actions  of  their  care  provider  teams.  Some  women  felt  that  while  in  labor  they  lost  their  resolve  and  motivation  to  speak  for  themselves  in  many  cases,  and  what  seemed  to  happen  in  such  times  is  that  staff  acted  in  a  way  that  was  as  if  the  women  were  not  in  the  room  when  they  spoke,  (IN7;;  IN12;;  IN11;;  IN15;;  IN9).  Other  times  women  stated  that  staff  would  come  to  look  at  the  machines  in  their  birthing  rooms  and  not  first  speak  to  them  (IN11,  IN9).  One  woman  accounted  for  an  incident  when  she  brought  attention  to  one  staff  member  that  they  had  not  introduced  themselves  to  them  first  before  acting  on  the  women  (IN15).  At  times  when  women  had  consented  to  a  major  procedure,  like  an  epidural  insertion  or  an  emergent  c-­section  the  staff  would  begin  to  do  many  things  to  prep  the  women  without  actually  explaining  what  they  were  doing,  so  women  describe  being  prodded  and  pulled  at  in  various  ways  which  gave  them  such  a  strange  feeling  of  being  acted  upon  without  them  knowing  what  was  happening  exactly  (IN10,  IN7).  Conclusion     Through  an  early  analysis  of  the  data  we  are  able  to  see  that  many  of  the  women  had  ambivalent  feelings  towards  the  circumstances  surrounding  their  hospital  birth  environments  due  to  certain  common  components  of  the  environments.  These  components  were,  interactions  with  others,  foreign  and  unfamiliar  clinical  procedures  and  processes,  hospital  rooms  and  equipment,  women’s  expectations  influencing  their  feelings  of  affinity  with  their  birth  environments,  emergency  procedures  influencing    117 feelings  of  fear,  feelings  of  helplessness  resulting  from  times  of  uncertainty  and  loss  of  control,  and  times  of  uncertainty  influencing  feelings  of  fear.  The  fact  that  the  women  in  our  study  often  had  these  feelings  of  ambivalence  towards  the  hospital  birth  environments  shapes  our  understanding  of  how  hospital  birth  environments  locally  are  a  major  contributing  factor  to  women’s  lasting  and  in  the  moment  feelings  about  their  births  and  labours  in  hospital  and  how  this  can  influence  their  perceptions  of  their  fear  of  childbirth.         118 Appendix  H:  Reflective  Note      July  25th,  2016   Transcribing  Notes.  P  5    At  time  signature  of  10  minutes  and  50  seconds    I  am  reflecting  on  the  significance  of  the  kindness  of  the  anesthesiologist  in  her  account  of  what  it  was  like  to  ask  for  two  support  people  to  be  present  for  her  c-­section.    What  I  am  thinking  is  regardless  of  why  he  agreed  to  her  request,  the  result  was  that  all  the  fear  she  felt  went  away.      I  need  to  make  sure  I  am  not  assuming  things  I  cannot  determine.  I  have  a  great  many  assumptions  about  the  dynamics  between  the  nurse  who  first  implied  that  the  woman  would  not  be  able  to  have  this  done  the  way  she  wanted,  and  the  anesthesiologist.  These  assumptions  are  based  on  my  own  experience  and  what  I  perceive  as  a  culture  of  conflict  that  occurs  between  nurses  and  consultants  in  some  cases.      This  story  is  important  but  not  for  the  system  implications  that  I  first  think  about,  it  is  important  because  the  woman  is  discussing  how  important  the  personalized  care,  and  being  listened  to  were  for  the  decreasing  of  her  fear  in  that  moment,  she  discusses  that  she  felt  she  was  in  a  fight  or  flight  mode  after  the  nurse’s  interaction  with  her  and  very  calm  and  more  excited  about  the  birth  after  the  anesthesiologist  agreed  to  her  request.           119 Appendix  I:  Thank  You  Letter   Dear Participant,   I want to express sincere gratitude for your participation in the research study investigating influences of hospital birth environments on labouring women’s perceptions of fear of childbirth. Your contribution to this study will impact further understanding on this phenomenon and this important information could not have been accessed by any other means.   Attached to this letter is a summary of findings from the study. I ask that you review the summary of findings and inform me if you have concerns or questions about the material presented. It is important that these findings represent the combined work and ideas of all the participants and myself, the researcher, so any feedback from you is gladly welcomed.  Please feel free to contact me if you have any further questions about this study and findings now that your participation is complete. Or you may also contact the Principal Investigator, Dr. Wendy Hall by email.     Best regards,   Jenny Auxier         


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