Understanding the significance of women’s experiences in maternity care

The World Health Organization’s recommendations on Intrapartum Care for a Positive Childbirth Experience¹ underscore the critical importance of women’s care experiences as a fundamental component of high-quality maternity care. The concept of Respectful Maternity Care (RMC)¹ which acknowledges women’s experiential or embodied knowledge as an essential element of woman-centered care, has been central to these recommendations. During labor and birth, women exhibit an increased sensitivity to their birthing environment, which notably includes their interactions with maternity care providers^2,3. Midwives and obstetricians through their intimate interactions with women during labor and birth are uniquely positioned to promote positive birth experiences, as the nature of these interactions plays a pivotal role in women’s psychological and emotional well-being during childbirth^3,4. Adverse interpersonal experiences with midwives, nurses, or obstetricians may leave lasting imprints on the maternal psyche, influencing perinatal health and well-being and potentially increasing vulnerability to posttraumatic stress disorder (PTSD)⁵. Research indicates that interpersonal trauma exerts a more profound influence on enduring PTSD symptoms than trauma stemming from emergencies or natural disasters⁶. This is particularly relevant to childbirth, where trauma from interactions with care providers has been reported to be as, if not more, prevalent than non-interpersonal trauma, including obstetric interventions and emergencies^7,8. Jolivet et al.⁹ pointed out that a notable lack of operational descriptions and definitions of the positive dimensions of RCM at the provider level may limit its practical implementation.

This methodology article aims to spotlight, from an interprofessional perspective, the critical role of the QPI in enhancing access to respectful care and positive childbirth experiences for women.

Exploring the dynamics of women’s relationships with maternity care providers

Neurohormonal changes in the maternal brain during childbirth, indicating specific mechanisms that alter states of consciousness, render women particularly susceptible to environmental influences during labor and birth^2,10. This sensitivity notably extends to interactions with intrapartum care providers. Contemporary research shows that for women to perceive childbirth as positive, they need to feel supported, in control, safe, and respected¹¹. The heightened environmental sensitivity of women during childbirth underscores the importance of supportive care, which has been shown to bolster physiological labor processes and enhance women’s feelings of control and confidence¹². Women consistently rate emotional support as the most vital form of support during labor, helping them stay focused and empowering them with resilience and courage¹³. This highlights the necessity for healthcare providers to have excellent communication skills that enable them to provide the crucial emotional support required during labor.

Emotional support is also integral to women’s perception of safety during childbirth¹⁴. Care providers can signal to be emotionally available to act as a secure base for women, offering a safe haven during the challenging and intense experience of childbirth¹⁵. Calming and supportive interactions initiated by care providers can stimulate oxytocin release, reducing fear, stress, and pain¹⁰. Moreover, clear, sensitive, and open communication by care providers is vital for women’s sense of control during childbirth¹⁶.

Midwives and obstetricians recognize that care delivered in a relational context with the woman, fosters positive interactions which are essential for negotiating optimal intrapartum care¹⁷. For midwives, the concept of ‘being with’ a woman encapsulates the commitment to addressing the woman’s physical and emotional needs during labor and birth¹⁷. Maternity care professionals themselves benefit from establishing positive relationships that foster meaningful interactions with women in their care¹⁸. Obstetricians and midwives experience increased job satisfaction and occupational well-being when they are able to form significant relationships with childbearing women¹⁷, underscoring that high-quality relationships and interactions are central to the professional identity of maternity care providers. Challenges such as high woman–provider ratios due to staff shortages and increased workloads can lead to a task-centric rather than woman-centric approach in providing maternity care, potentially hindering the achievement of high-quality interactions¹⁹.

Conceptualizing Quality of Provider Interaction (QPI) in maternity care

The term ‘Quality of Provider Interaction (QPI) pertains to a woman’s perception of her care provider’s interpersonal verbal and non-verbal behaviors²⁰. Interaction in this context is broadly conceptualized as a cognitive and action-based process encompassing physical acts and verbal or non-verbal communication¹⁹. Sorenson’s scale ranges from ‘disaffirmation’ to ‘affirmation’, with ‘affirmation’ representing interactions that acknowledge and support a woman’s individuality and personhood. In contrast, ‘disaffirmation’ denotes interactions of lower quality, where a woman’s personhood is disregarded, and she is treated as an object²⁰. Research shows that QPI has a significant influence on how women feel during labor and birth^4,5,21, which has a major effect on their overall childbirth experience²² and emphasizing the importance of QPI in understanding the full scope of childbirth. Continuity of care models, which enable and emphasize relational aspects of care, are more likely to promote high QPI²³. The concept of QPI underscores the importance of women’s perceptions during birth and is thus crucial to a woman-centered approach to understanding birth experiences²⁴.

High quality provider interactions, as perceived by women, often result in psychological safety during labor and birth⁴. Women have expressed the profound impact of positive interactions with maternity care providers using emotive language, describing these experiences as deeply caring, supportive, and even healing²⁵. Interactions with maternity care providers that embody support and respect and that foster feelings of control and safety can lead to joy, confidence, and long-term positive psychosocial effects. These elements are integral to positive childbirth experiences¹¹.

Conversely, low-quality provider interactions, marked by a lack or total absence of caring, personalized, and humanizing interactions, heighten the risk of traumatic childbirth experiences^5,21. Traumatic childbirth is defined as an overwhelming and distressing experience with short- and/or long-term negative impacts on a woman’s health and well-being²⁴. Women who feel unsupported or abandoned, particularly those with histories of sexual abuse, are more susceptible to perceiving childbirth as traumatic²⁶. Negative or traumatic birth experiences often correlate with perceptions of coercive and disrespectful care environments³.

Women describe negative interactions with maternity care providers as leaving them feeling disempowered, desolated, suppressed, violated, and disregarded in their human rights²⁷. Such low-quality interactions with providers may exacerbate the effects of already existing mental health conditions, potentially leading to postpartum depression²⁸ and birth-related posttraumatic stress disorder (BR-PTSD)⁵. Achieving high-quality interactions in maternity care presents a challenge; although certain individual and pre-existing characteristics may make it easier to create a positive relationship, it is not an innate skill but rather necessitates training, evaluation, and continuous improvement²⁰.

This article is a collaborative synthesis of insights from two members of the ‘Optimizing the birth environment’ COST Working Group, part of the broader COST Action DEVOTION CA18211 (2019–2023) pan-European research network aimed at addressing birth trauma and enhancing childbirth experiences on an international level²⁹. This effort taps into the research expertise in birth trauma of both authors, their complementary clinical experience in midwifery and obstetrics, and their involvement in education and policy-making. Our discourse has centered on the imperative for synergistic and respectful interprofessional dynamics within maternity care teams, emphasizing woman-centered communication as fundamental.

The development of this expert opinion piece was propelled by a sequence of targeted discussions, emphasizing the significance of QPI in maternity care. These discussions were enriched by in-depth engagements with our working group, a critical review of scholarly work produced across the COST Action’s spectrum of working groups, and active contributions to COST Action conferences. This interprofessional exchange was vital for distilling the insights and recommendations presented herein.

The current article further articulates strategies to promote, develop, and sustain these key facets within global maternity care practices, tailored to the midwifery and obstetric academic audience. Merging our research with the collective expertise garnered through our COST network engagement, we endeavor to provide a nuanced perspective aimed at enhancing birth experiences and reducing trauma through improved provider interactions. This work seeks to advance midwifery and obstetrics globally, advocating for maternity care practices rooted in empathy, respect, and empowerment.

Empathy and emotional availability

Empathy from providers is fundamental in establishing a trusting therapeutic relationship and is a critical component of the QPI³⁰. Within the context of intrapartum care, empathy encompasses: 1) understanding the woman’s perspective and feelings, 2) communicating this understanding, and 3) acting upon this understanding in a therapeutic manner³¹.

Recent midwifery and obstetric literature has placed increasing emphasis on the affective competencies of intrapartum carers, including empathic communication with childbearing women^32,33. In a study among over 2000 women with traumatic delivery experiences, they reported communication, listening to them, and supporting them better/more emotionally and practically as the top-three things caregivers could have done to prevent their traumatic experience⁷.

The need for a connection between women and their intrapartum caregivers that transcends cognitive empathy, encompassing emotional responsiveness, and availability, has been advocated¹⁵. Burnout among maternity care providers can diminish empathetic capacities, and has been linked to high workload, exposure to traumatic events, and lack of professional autonomy³⁴. The opposite has also been identified high empathy may predispose to emotional distress, particularly in high-workload and highly protocolized settings with low professional autonomy⁸. Focusing on organizational interventions rather than solely on individual actions is pivotal in mitigating burnout among maternity care professionals, as it addresses the structural and systemic factors contributing to the problem³⁵.

Diminished empathy occurs when a provider sees someone not as an individual with their own emotions but as an object³⁶. This perspective makes achieving high QPI impossible. Correspondingly, a lack of empathy is a critical component in the development of disrespectful and abusive maternity care practices³⁷. Thus, fostering a culture of empathy and emotional attunement in maternity care professionals is imperative for the enhancement of QPI and the assurance of dignified, supportive care experiences for childbearing women.

Trauma-informed maternity care

At the time of birth, psychological and emotional safety for women is enhanced through the provision of trauma-informed care. This approach entails organizations and individuals recognizing the high prevalence and extensive impact of trauma, understanding potential recovery pathways, identifying signs and symptoms of trauma, integrating this knowledge into policies and practices, and actively avoiding actions that could cause re-traumatization³⁸.

The physiological aspects of pregnancy and childbirth, coupled with the nature of maternity care interactions, particularly those of lower quality, can potentially trigger recollections of prior traumatic experiences in childbearing women⁵. Research indicates a high prevalence of adverse childhood experiences (ACEs) among women, especially those from lower socioeconomic backgrounds, many of whom have also endured various forms of trauma³⁹.

The creation of a safe environment commences with supporting women during pregnancy to prepare for childbirth and the possibility of it evoking memories of past traumas³⁸. Care providers who dedicate time to discussing women’s preferences, anxieties, and birth plans foster empowerment and a positive mindset, which bolsters women’s autonomy and aids in setting realistic expectations for childbirth.

Effective communication and interactions with maternity care providers significantly enhance childbearing women’s sense of control, a crucial factor in preventing re-traumatization during maternity care for women with a history of abuse⁴⁰.

During labor and birth, aspects such as care providers introducing themselves, speaking in calm, soft tones, knocking before entering, dimming lights, and avoiding standing behind the birthing woman contribute to a sense of her being in control and feeling safe. Additionally, empowering the woman to make choices about her immediate birthing environment (e.g. companions, music, lighting, temperature) and how she wishes to manage her contractions (e.g. birthing positions, intuitive pushing) minimizes disruptions to the natural birth process. These practices also support the subduing of the neocortex, thus facilitating the limbic system’s role in guiding the birth process².

Trauma-informed maternity care is closely linked with QPI; the two concepts support and enhance each other. For maternity care to be truly trauma-informed, high-quality interactions between maternity care providers and childbearing women are essential. Similarly, effective trauma-informed practices improve these interactions. Achieving such a level of care requires training maternity care providers workers in trauma-informed principles, ensuring all interactions align with these important values.

Integrating woman-centered individual and institutional attitudes

The attitudes of intrapartum care providers significantly impact the QPI and, consequently, shape women’s experiences of labor and birth³. These attitudes are not only individual but can also be entrenched within the institutional culture where care providers operate⁴¹. It is essential for maternity care providers to be aware that the institutional culture of their workplaces interacts with the practices and attitudes of individual care givers. Midwives have expressed they are often not able to reconcile working according to institutional requirements with their ‘with woman’ philosophy⁴². Only when realized together, woman-centered provider and women-centered institutional attitudes have the potential to mark a progression to a transformative approach in maternity care, placing the woman’s needs, preferences, and autonomy at the heart of the care process.

This approach is recognizing the woman as the central figure in her childbirth journey and highlights the importance of her subjective experience when giving birth. Woman-centered care is characterized by a commitment to listening to and valuing the woman’s voice, ensuring her active involvement in decision-making, and tailoring care to meet her unique cultural, personal, and medical needs⁴³. By focusing on the woman’s individual journey, a deeper understanding and respect for the diverse experiences of childbirth is fostered, thereby enhancing the overall quality of maternity care.

Attitudes also encompass risk perception and risk aversion. This spectrum includes a variety of practices, such as efforts to facilitate vaginal birth, normalization of interventions, valuing medical knowledge and expertise vis-à-vis women’s preferences, planning care (e.g. induction, cesarean section) based on practical or logistical considerations, and support for women’s choices that diverge from standard medical advice or protocols. Attitudinal elements also encompass awareness and capability to foster a safe and respectful care environment.

Research has identified an increasing trend towards risk-averse behavior among maternity care professionals⁴⁴ and the same could be true for pregnant women themselves. This trend includes defensive medicine, defined as deviations from optimal practice primarily to avert patient or caregiver complaints⁴⁵. When maternity care is steeped in a risk-averse, fear-based culture, it limits both caregivers’ and women’s sense of responsibility and decision-making autonomy during childbirth. Providing maternity care in a fear-based environment can lead to an overreliance on unnecessary interventions and surveillance, shifting the focus away from the unique needs of each woman⁴⁴.

Thus, it is essential for maternity care providers to critically evaluate both their personal approach and the institutional attitudes of their workplaces, understanding how these perspectives interact to shape perceptions of risk, care practices, and interactions with the women under their care. Such awareness is fundamental in enabling providers to engage respectfully and sensitively with women in their care, thereby enhancing the overall quality and safety of maternity care experiences.

Empowering language use

In light of the critical role that both verbal and non-verbal communication play in determining the QPI and women’s childbirth experiences⁷, it becomes crucial for care providers to fully comprehend the power of language in healthcare settings⁴⁶. Effective communication, as highlighted by Cox and Fritz⁴⁷, is fundamental to meaningful interactions. The language used in midwifery and medical contexts, especially with terms like ‘high risk’, ‘allowed to’, and ‘trial of labor’, can inadvertently disempower women. The linguistic choices made by healthcare professionals not only shape their perception of childbearing women but also potentially influence how these women view themselves, affecting their sense of agency and capacity for autonomous decision-making. Equally important is non-verbal communication, such as tone, volume, and non-verbal expressions, including facial cues and body language, which can also contribute to or detract from women’s empowerment.

To ensure a high-quality QPI and a positive childbirth experience, the language adopted by midwives, nurses and obstetricians should be empowering, factual and propagate an equitable relationship between women and care givers – this can be achieved by clear, respectful, empathetic, realistic, and non-judgmental language while adhering to the principles of shared decicion making. To promote women’s well-being during childbirth, this language should be predominantly positive, with an emphasis on possibilities and options, except in situations where positivity is not feasible⁴⁸. Inspired by previous literature^46,47,49, Table 1 outlines a set of recommended practices (‘dos’) and behaviors to avoid (‘don’ts’) in language use. This guidance is intended to equip care providers with the tools to create a supportive and empowering environment for women, thereby enhancing their autonomy and the overall quality of the childbirth experience.

Maternity care providers must be vigilant in their use of language, as it plays a pivotal role in shaping attitudes and perceptions. It is imperative to employ language that builds trust, mitigates power imbalances, and promotes shared decision-making. The practice of informed consent and shared decision-making, alongside actively involving women in discussions about the management and interventions of labor and delivery, are crucial. Such practices enhance the autonomy of birthing women, bolstering their sense of control, which is critical for reducing the risk to experience birth trauma. Strong, empowering relationships between women and their maternity care providers, founded on sensitive, respectful, and trauma-informed interactions, enrich women’s overall birth experiences. These relationships thrive on effective communication and a collaborative approach to decision-making.

The BRAIN acronym, advocated by the International Childbirth Education Association⁵⁰ serves as an effective tool for facilitating the provision of information, aiding shared decision-making, and ensuring informed consent. This tool is versatile, it can be used by women to ask pertinent questions about their care (Table 2), or by providers to clearly explain the benefits and drawbacks of various care options or management strategies. This approach empowers women to make informed decisions and enhances the quality of the maternity care experience.