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Painfulness and Happiness of Childbirth Essay

Introduction, works cited.

Becoming a mom is an extraordinary experience, full of excitement and happiness. Nine months of pregnancy for a woman is a lifetime, during which there is a unique communication with the child, and maternal feelings are formed. The process of giving birth to a baby can and should be one of the most significant and bright moments in life for a woman in labor. To do this, every woman needs to prepare for this magnificent event. Although the birth of a child carries some painful sensations, the birth of a baby can still be the happiest moment in a woman’s life.

Undoubtedly, in my case, childbirth has become one of the most painful but happiest events in my life. The birth of a child takes place in three stages, the first of which is the process of opening the cervix. Mencarini et al. state that it begins when contractions become regular and end with the complete opening of the cervix, and this stage is one of the most painful (7). When the cervix was fully opened and the baby was ready to pass through the birth canal, I was inspired and supported by the realization that very soon, I would see my child and receive my reward for my labors. The second stage is associated with the child’s passage through the birth canal; it begins after the complete opening of the cervix and ends with the birth of a child (Downe et al. 12). It also causes quite a lot of discomfort and physical pain. The last stage is the expulsion of the placenta. It usually goes away quickly and painlessly compared to the previous two.

For me, the primary source of joy was the knowledge of an imminent meeting with my baby, the realization that his first birthday would take place very soon. The completion of pleasure comes at every stage of a child’s life: when he begins to look, walk, talk and laugh. The baby’s birth was an unforgettable moment and very happy not only for me but also for many mothers.

It must be said that childbirth is a physiological process, and, as everyone knows, no physiological function in our body is accompanied by pain, except for complications caused by illness, fear, and tension. Accordingly, in the presence of a positive psychological mood for childbirth, the absence of anxiety and stress, a woman rarely experiences significant discomfort during childbirth (Bayat et al. 2). Thus, the main idea that every woman should learn is that a positive attitude to childbirth, knowledge, and mastery of relaxation methods during childbirth is the key to a happy birth.

All women have the same scenario of development. However, each woman has her version of the scenario. Moreover, if a woman gives birth for the first time, all she feels is a new experience. Therefore, they talk about a situation of some uncertainty in childbirth. Women will need courage and willingness to make decisions according to the problem, here and now (Nejad et al. 1082). A woman needs to work hard mentally and show self-control and patience, but patience is an essential maternal quality.

In conclusion, the birth of a child is quite a painful process for every woman. Nevertheless, the happiness that the newly appeared mother will experience from the baby’s birth will be worth the suffering that she experiences during childbirth. Despite all the difficulties and possible pain, it would be wonderful if every woman experienced the happiness of having a baby. The recommendation that I could give to every woman would be to maintain the motivation to accept and live childbirth.

Bayat, Arezoo, Amiri‐Farahani, Leila, Soleimani, Mehdi, Eshraghi, Nooshin, and Haghani, Shima. “ Effect of short-term psychological intervention on anxiety of pregnant women with positive screening results for chromosomal disorders: a randomized controlled trial .” BMC Pregnancy Childbirth, vol. 21, no. 757, 2021, pp. 1-11. Web.

Downe, Soo, Finlayson, Kenneth, Oladapo, Olufemi, Bonet, Mercedes, and lmezoglu, Metin. “What Matters to Women During Childbirth: A Systematic Qualitative Review.” PLoS ONE , vol. 13, no. 4, 2018, Web.

Mencarini, Letizia, Vignoli, Daniele, Zeydanli, Tugba, and Kim, Jungho. “ Life Satisfaction Favors Reproduction. The Universal Positive Effect of Life Satisfaction on Childbearing in Contemporary Low Fertility Countries .” PLoS ONE , vol. 13, no. 12, 2017, pp. 1-19. Web.

Nejad, Farnaz, Nejad, Fahimeh, Golmakani, Nahid, Khajehpoor, Mahin, and Mayvan, Fatemeh. “The Relationship between Happiness and Fear of Childbirth in Nulliparous Women.” Journal of Midwifery and Reproductive Health , vol. 5, no. 4, 2017, pp. 1082-1089. Web.

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Essays About Motherhood: Top 6 Examples And Prompts

 If you are writing essays about motherhood, see below our list of essay examples and prompts for inspiration.

Motherhood refers to the activities and experiences of a female parent in raising a child. It can be enjoyed not only through the biological process of giving birth but also through adoption or parenting the biological children of a spouse. 

Mothers have a vital role in society as they are responsible for shaping and empowering individuals who can make or break the world. There is an abundance of stories on mothers’ joys, challenges, and sacrifices that are always riveting and heartwarming to any reader. 

Here is our round-up of examples and writing prompts that can inspire you when writing your essay about motherhood: 

1. Housewife Vs. Working Mom: Enough With the Arguing! by R.L. 

• 2. “Mom Brain” Isn’t A Joke by Julie Bogen

3. Why Daughters Fight With Their Mothers by Eleanor Barkhorn

4. coming out to my mom: a letter to mothers of gay sons” by brandon baker, 5. why moms make better managers by all things talent team, 6. lessons from my mother by james wood, 1. sacrifices of mothers, 2. write about your mom, 3. mothers coping in the pandemic, 4. mothers as bosses, 5. mental health therapy for mothers, 6. workplace discrimination against mothers, 7. more support for single moms, 8. how to deal with toxic mothers, 9. feminism and motherhood, 10. motherhood in different cultures, top 6 essay examples.

“The point is there’s no one ultimate decision that fits all mothers… Enough with the ridicules and the sneering. If you are happy with your choice then enjoy it! You don’t need to make other people feel insufficient or even guilty for taking a different path.”

The essay urges working and stay-at-home moms to stop looking down on one another for having different life choices and perspectives on child-rearing. All mothers do all they can to nurture their families the best way they know. So instead of judging and attacking fellow moms, they should make peace with each other and have a group hug. You might also like these essays about your mom .

2. “ Mom Brain” Isn’t A Joke by Julie Bogen

“…[W]hat we think of as mom brain ‘is a product of the unequal burden that we have placed on women to do both the physical caregiving for children and also the logistical and mental work of caring for a whole household.’”

The author debunks the misconception of “mom brain” – forgetfulness of moms – caused by physiological changes from motherhood. Instead, she points the finger at chronic stress due to society’s unreasonable expectations for mothers to do all the heavy lifting at home and work. She then encourages society to step up its support for mothers through policy reforms and simple acts such as splitting chores.

“These conflicting desires — the mother’s desire to protect versus the daughter’s desire for approval — set the stage for painful misunderstandings and arguments.”

The author interviews a linguist who analyzes the reasons behind tense mother-daughter relationships and identifies the three most significant sources of friction in these bonds. The linguist also provides tips to mothers and daughters to ease tension and prevent future wars with one another. If you’re expecting, you might be interested in our guide on the best pregnancy books .

“… [T]here’s something inherently more weighty about a mother’s approval… So, if anyone’s going to love you unconditionally, it’s her. And if she’s not on board with you now, you muse in the moment, what does that say about you?”

Baker tells his story of coming out to his mother through email. The article also directly speaks to moms who have difficulty understanding the coming out of their children. At the very least, he encouraged confused mothers not to make their LGBT children feel less of a person as their opinions mean the world to their sons or daughters.

“Moms are the best managers because parenthood is one of the most basic forms of leadership. Tons of patience, empathy, planning, organising, innovation, and negotiation gets added to your personality with a child in your life.”

The article lists the top traits that make mothers the best managers. These qualities include their multitasking expertise, empathetic approach, comprehensive “Plan B” planning, excellent negotiation skills, and innovativeness, making them ideally suited to handle the pressures and demands in top positions.

“All sons adore their complicated mothers, in one way or another. But how powerful to encounter, from someone else, the beautifully uncomplicated statement ‘I adored her.'”

In the essay, the author reminisces the rich life of his mother, who recently passed away. But soon, he discovers the broader circle of his mother’s influence which makes him adore his mother more. 

10 Prompts on Essays About Motherhood

Here are our most thought-provoking prompts on motherhood:

While mothers find their true love and joy in being a mom, many gave up some luxuries and even ambitions, at least temporarily, to focus on raising their children. For instance, some women forego building their careers during their children’s critical years of development. For this prompt, list down and describe the common sacrifices of mothers. You can also write about what your mother had to give up to spend more time with you and let you live a happier life. 

Describe your mom. Talk about her antics, her antics, and her ways. You may recount your most joyful memories with your mom. In addition, list the lessons you learned from her or talk about how she lived her life. Put in as much information about the memories while still keeping the focus on your mom. 

The pandemic has flooded mothers with an overwhelming amount of challenges. For one, they were forced to balance professional life and homeschooling as daycare centers and schools were shut down. So, first, interview working mothers and write about their quarantine challenges and how they overcame that difficult phase. What lessons were learned? What kind of support would they like to have moving forward? Then, write their responses to these questions. 

Several studies show how many mothers stand proud at the top of the corporate ladder. Interview mothers who are CEOs, founders, or have managerial positions. Learn how they gained their positions while dealing with responsibilities at home. Next, find out what women CEOs bring to the table that makes them the leaders their organizations need. Finally, ask what advice they would give to mothers aspiring to be bosses in their workplace.

With most moms being the primary caregivers to their children, they need stable mental health in performing their responsibilities. So, explain why some mothers feel sad and hopeless after birth. Then, explore the different treatment strategies to fight depression or anxiety during and after pregnancy. 

Denying women a job because of their motherhood is unconstitutional. Yet, this practice remains pervasive in several workplaces. Research on the standard employment challenges of mothers and existing laws that prohibit work discrimination against mothers, if any. Recommend some ways how the government and the corporate world can fight work biases against moms and help them prosper in their jobs. 

Single moms face a myriad of prejudices. Some critics use existing data and studies showing that children of single moms tend to be school dropouts or even criminals. Write about how government and the whole of society can step in to stop the judgment on mothers. First, paint a vivid picture of the struggles of single moms to provide context. Then, suggest reforms that could best aid them in raising their children. 

Write about the traits that make a mother toxic. Some examples could be their lack of boundaries, self-centeredness, and being overly critical. Then, write about the negative impact these traits have on daughters’ mental and emotional well-being. To conclude, you can discuss the treatment options to mend rifts between mother-daughter relationships. 

Feminism and motherhood have often been at loggerheads with one another—research what radical feminists say about motherhood. Dive deep into why they find motherhood contradicting the sacrosanct feminist principles. But on the other hand, you can also explore how feminism devalued the role of mothers in society. 

Explore different cultural standards on how mothers raise children. In addition, you can describe unique styles of motherhood across countries. It would also be interesting to tackle the different cultural practices in helping women have a baby or post-care traditions. Finally, you can also explore how hospitals and healthcare professionals tailor their services to accommodate these special cultural needs. 

For help picking your next essay topic, check out our 20 engaging essay topics about family .

If you’re still stuck, check out our general resource of essay writing topics .

Yna Lim is a communications specialist currently focused on policy advocacy. In her eight years of writing, she has been exposed to a variety of topics, including cryptocurrency, web hosting, agriculture, marketing, intellectual property, data privacy and international trade. A former journalist in one of the top business papers in the Philippines, Yna is currently pursuing her master's degree in economics and business.

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• Research article
• Open access
• Published: 09 October 2015

The meaning of a very positive birth experience: focus groups discussions with women

• Annika Karlström 1 ,
• Astrid Nystedt 2 &
• Ingegerd Hildingsson 1 , 3  

BMC Pregnancy and Childbirth volume  15 , Article number:  251 ( 2015 ) Cite this article

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The experience of giving birth has long-term implications for a woman’s health and wellbeing. The birth experience and satisfaction with birth have been associated with several factors and emotional dimensions of care and been shown to influence women’s overall assessment. Individualized emotional support has been shown to empower women and increase the possibility of a positive birth experience. How women assess their experience and the factors that contribute to a positive birth experience are of importance for midwives and other caregivers. The aim of this study was to describe women’s experience of a very positive birth experience.

The study followed a qualitative descriptive design. Twenty-six women participated in focus group discussions 6–7 years after a birth they had assessed as very positive. At the time of the birth, they had all taken part in a large prospective longitudinal cohort study performed in northern Sweden. In the present study, thematic analysis was used to review the transcribed data.

All women looked back very positively on their birth experience. Two themes and six sub-themes were identified that described the meaning of a very positive birth experience. Women related their experience to internal (e.g., their own ability and strength) and external (e.g., a trustful and respectful relationship with the midwife) factors. A woman’s sense of trust and support from the father of the child was also important. The feeling of safety promoted by a supportive environment was essential for gaining control during birth and for focusing on techniques that enabled the women to manage labour.

It is an essential part of midwifery care to build relationships with women where mutual trust in one another’s competence is paramount. The midwife is the active guide through pregnancy and birth and should express a strong belief in a woman’s ability to give birth. Midwives are required to inform, encourage and to provide the tools to enable birth, making it important for midwives to invite the partner to be part of a team, in which everyone works together for the benefit of the woman and child.

Peer Review reports

The experience of giving birth has long-term implications for a woman’s health and wellbeing [ 1 , 2 ]. Satisfaction with birth has been associated with several factors and the emotional dimensions of care have been shown to influence women’s overall assessment. Individualized emotional support empowers women and increases the possibility of a positive birth experience [ 3 ]. Support from the midwife during labour and birth and the opportunity to participate in decision-making are also important [ 4 ].

Woman’s perceived control during birth is significant [ 5 , 6 ]. Findings from a mid-European study show that the most important factor contributing to a woman’s satisfaction with birth was having her expectations fulfilled. Self-efficacy and personal control were other factors related to satisfaction with birth. The experience of personal control had a protective effect on labour pain [ 7 ]. Dutch women assessed their birth experience as very happy when answering a questionnaire where five options were available; from very happy to very unhappy. In a description of caregivers, the most frequently chosen positive adjectives were supportive and considerate [ 8 ]. In a prospective, longitudinal study, 303 women (32.7 %) had a very positive birth experience assessed on a five-point Likert scale ranging from very positive to very negative [ 9 ].

Furthermore, women’s views of and satisfaction with maternity care are important indicators of quality service provision [ 10 ]. A recent major focus has been to identify the prevalence of (and associated factors for) a negative birth experience in order to improve care. Although equally as important, research relating to the factors associated with a positive birth experience have been less well studied. Learning from women’s birthing stories and adapting care during birth based on what women actually consider important will likely enhance the birth experience and promote normality in the context of the much medicalized birth environment.

Obstetric outcome is a major measure of the quality of care provided. However, how women assess their experience and the factors that contribute to a positive birth experience are also of importance for caregivers. The aim of this study was to describe women’s experience of a very positive birth experience.

Obstetric context

Antenatal care in Sweden is organized within the public primary health care system with the midwife as the primary caregiver, providing care for pregnant women within a certain geographical area. Care during labour, birth and the postnatal period occurs in hospitals with midwives as the independent caregiver for uncomplicated cases. A nurse assistant is intermittently present during labour and birth and assists the midwife with practical care and support of the birthing woman. Midwives work in collaboration with obstetricians if complications occur. There are few alternative birth settings in Sweden and continuity of caregiver between episodes of care is rare. The prevalence of home births for Sweden is about one per thousand.

This project was part of a large prospective longitudinal cohort study undertaken in northern Sweden in 2007. Data was initially collected by self-administered questionnaires. Women were approached to participate in the study after their ultrasound examination at gestational week 17–19 and subsequently followed-up at late pregnancy (32–34 weeks) and at 2 and 12 months post-partum. The questionnaires covered a wide range of questions, including questions addressing socio-demographic and obstetric background, attitudes, expectations and experiences related to childbirth. Answers to two questions were the inclusion criteria for participation in the study reported here. The first question, concerning women’s perception of their birth experience, was collected at 2 and 12 months post-partum. The second question was included in the third questionnaire where women agreed to be contacted for an interview. Women’s perception of birth was assessed on a five-point Likert scale ranging from very positive to very negative. A detailed description of the methods in the longitudinal cohort study is presented elsewhere [ 11 ].

Participants

Women who had assessed their birth as very positive at 2 months post-partum and consented to participate in an interview were invited to take part in focus group discussions. A letter of invitation was sent to 197 women.

Focus groups interviews

Interviews were performed between September 2013 and February 2014. The timing of the interviews was chosen partly due to practical reasons but foremost in the belief that women need time to process their experience. Focus group discussions were held in a conference setting at the university or at the primary health care center nearby to where women lived. The discussions lasted 2–3 h and were audio taped. Two researchers were present at each interview; one of the researchers started the session with a short presentation of the project and the other took notes. The participants were asked to present themselves and talk shortly about their present situation. The discussion started with an open-ended question: “Please tell us about your very positive birth experience and the importance of it.” Women were specifically asked to reflect on a birth that occurred in 2007 or 2008 (index birth).

Thematic analyses

A qualitative descriptive approach was used in this study [ 12 ]. Thematic analyses were used to analyze the transcribed focus group data [ 13 ]. Three researchers thoroughly reviewed the transcripts to gain a fuller sense of their meaning. Initial concepts that emerged were discussed and coding was performed to identify patterns of words or statement that were related to the aim of the study. Next, all codes were examined and compared to clarify relationships, and the various codes were sorted into sub-themes. The intention during this process was to stay close to the words through a constant movement between the whole and the parts of the text. The accuracy of how to sort codes with similar content into sub-themes was confirmed in discussions in which all co-authors participated and agreed. In the final step, two themes were formulated to describe women’s very positive birth experiences.

All researchers are midwives with long experience of intra-partum care. The researchers paid careful attention throughout the interviews and analyses to the pre-understanding that inevitably will influence the interpretation of women’s birth stories.

Ethical considerations

The prospective longitudinal cohort study was approved by the Ethical Committee at Umeå University (05–134 Ö). The approval for the larger prospective longitudinal cohort study included this study. In the third questionnaire women gave a written consent to be contacted for an additional interview. The invitation letter sent to the women made it clear that the time elapsed since their approval of participation in interviews was of importance. For example, things might have happened that made it no longer possible for the women to participate. The women were also assured that, at any time, they could withdraw from the focus group’s discussion. Several women had given birth after the index birth but none of them were pregnant at the actual focus group session.

Initially, 197 of the 212 eligible women fulfilled the inclusion criteria and were sent a letter of invitation to participate in focus group discussions. Of the 59 responses, 30 women agreed to take part, with 26 of these fulfilling the appointment. Seven focus groups were carried out with 2–6 participants in each group. Women were aged between 28 and 46 years with a mean age of 36. They were all born in Sweden, married or cohabiting and gave birth in hospital. Most women had a higher level of education (18/26). The majority of women gave birth vaginally except two women who had an emergency caesarean section. There were 9 primiparous women in the study group.

Six to 7 years after delivery, all women looked back very positively on their birth experience. Women spoke mostly about the birth they had assessed as very positive, but comparisons were also made about previous or later births. Two themes and six sub-themes were identified that described the meaning of a very positive birth experience, as shown in Table  1 .

Many expressions were used to describe the birth experience. Frequently used words included fantastic, wonderful, magic, incredible and overwhelming. When women were asked to further develop the feelings they had experienced during birth, they spoke about being in a flow, fully engaged and participating, feeling safe and secure, close to the earth, experiencing happiness through a very special journey, and an important moment of life. The women spoke with pride at having coped with the labour and pain, which made them feel thankful and relieved. They also talked about child birth as an outstanding experience that they felt positive about experiencing again.

Experiencing own ability and strength

The first theme is an expression of a general attitude among the women that became evident when listening to the birth stories. The women's approach towards childbearing was grounded in an attitude of trust in themselves and their ability to give birth. Feelings of confidence were clearly expressed in all focus groups and the women were convinced that they were able to handle the pain and other difficulties. It was suggested that their positive birth experience was related to their constructive and sympathetic attitude towards childbearing and life in general.

Mother and grandma have given birth; it is in our nature to do this. So it felt like I had a basic attitude that it would be simple. And it was. (First child, vaginal birth)

Or is it not so you are a certain person to have a positive birth? It doesn’t start with giving birth, but it is a general attitude. (Third child, vaginal birth)

Most of the participants believed this confidence led to positive expectations towards the coming birth. There was an agreement among participants in the focus groups that giving birth was something they looked forward to, and they were inspired by mothers, grandmothers and other important females held up as role models. To be pregnant and give birth were matters of course and a privilege. Birthing was described as a natural process for which the female body was designed, however, all of the focus groups agreed that expectations should be realistic. Knowledge about the birthing process and obstetric complications, such as prolonged labour and emergency caesarean, was considered necessary.

I had a model in my mother who had told me about her fine and normal births. I did not expect anything else. (Second child, vaginal birth)

It is a magic experience, but somehow you have to be aware of what it is about. When you talk about giving birth, I think it is important not to make it strange but to make it very concrete. (Second child, vaginal birth)

Physical and mental preparation was a necessity for most of the women, as was participation in classes. Individual preparation was also described as important. Women wanted to be taught about the practice of labour, including breathing and relaxation techniques, as well as how to be physically and psychologically prepared to give birth. They wanted their partners to be involved and acknowledged by the professionals. Physical and mental preparation, including knowledge about the birthing process, was necessary to achieve control and take part in decision-making. The women did not consider giving total responsibility to the midwife.

For me, the mental training was important…it was very good. We talked a lot about expectations, which is useful not only when giving birth, and about our relation that we do this together. (First child, emergency caesarean section)

I was prepared, I knew how to breath (during birth) and how to breastfeed. (Second child, vaginal birth)

Preparations before birth also meant that women were aware of potential obstetric complications and deviations from the normal birth process. A few women described a more expectant attitude towards birth and there was a general acceptance that pain and other difficulties were part of giving birth. Several women had experienced prolonged labour, emergency caesarean section or postpartum hemorrhage during the index birth. The pain was generally described as intense and stronger than expected, and was handled in different ways. Controlled breathing, mental training, and nitrous oxide were the most commonly used pain relief methods, with a few of the women having an epidural. The breast-feeding period was initially painful and troublesome for a few women, but irrespective of the origin of the pain, it was an expected challenge to overcome.

Something that is good to know before (you give birth) is that the pain is awfully intensive but then there is a break, between contractions you can really rest. (Second child, vaginal birth)

But you sort of forget and it is not a negative pain like an aching leg and not knowing for how long it will go on. It is a positive pain. (First child, vaginal birth)

The experience of control was mostly related to the management of pain but was also associated with the women having an active role during the course of birth. The women expressed feelings of being in charge and being involved in decision making. As important as control was the ability to let go, and the women discussed the need to relinquish control and to trust their body; to be in a relaxed mode and to await and work with the contractions. Control was related to the preparations that had been made prior to the birth. To be prepared and aware of the mental and bodily challenges involved in a birth made women more confident, as they knew what to expect and were more familiar with the birthing process.

I am sort of a control freak…my plan was to work with the breathing and mental training and it worked all the way. (First child, vaginal birth)

The thing I found so crucial was that you were in tune with your body, could listen to your body. That is what I mean with let go and find rest. (First child, vaginal birth)

Having trustful and supportive relationships

The second theme expresses the importance of having caring and loving persons around birthing women. The presence of the child’s father was essential for most women in the focus groups, as this made the woman feel safer; by confirming that he believed in her and thus strengthening her self-confidence. The presence of a midwife or the assistant nurse was another significant person who made the birth positive.

Feelings of safety were repeated like a mantra throughout the discussions. The experience of safety was initially promoted by the very first telephone contact, when the women announced their arrival to the labour ward. It was important for the women to be met with interest from the midwife and not to be questioned about the severity of the labour. Several women expressed that it was a positive experience not to be turned away during the early phase of the labour. Feelings of safety were further confirmed by a respectful welcome and positive atmosphere in the birthing suite. Many of the women felt that giving birth was basically their own task and challenge, but the knowledge that they were in a place where they felt safe deepened their feelings of a very positive experience.

I was taken care of in a good way and felt safe, and yes, I think this is basic. (First child, vaginal birth)

When I think about this first birth and why it was so positive, it had much to do with the people around me in control of the complication I had (postpartum hemorrhage). Still I felt safe and calm. (First child, vaginal birth)

A trusting relationship involved feelings of being seen and heard, which meant that women experienced support on their own terms. The engagement from the midwife and the other staff enabled the women to feel safe and to be able to do what they wanted. They felt comfortable to move about, take a bath or simply moan through a contraction. This could also include an early admittance to the labour ward or not being questioned about positions during labour but instead being free to act in the way that felt best. Being seen and heard made these women confident that they had the leading role and that all considerations were made to prioritize them and their babies.

For me, a big part of the positive experience was that I felt seen and provided for, and that I was taken care of. (Second child, emergency caesarean section)

Yes, my birth was a quick one, but I think that the care and the reception you get are important. And that it clicks with those you are going to work with. (First child, vaginal birth)

In all of the focus groups, it became clear among most women that giving birth requires teamwork, where the woman and her partner work together with the midwife. This teamwork also included the assistant nurse and made it possible that care throughout labour and birth was directly related to the needs of the woman and her partner. Some women actively wanted and appreciated the staff being present to support and assist, whereas others only wanted the staff to be around if needed.

I mean, we were two sharing the pregnancy and it was a very positive time expecting the first child, so fun and exciting like the best journey you have been on. I felt safe with him (during birth) and there was nothing strange. (First child, vaginal birth)

I soon felt a sense of cooperation with the midwife and the assistant nurse. This was something we would do together. (Third child, vaginal birth)

The role of the midwife was discussed in all focus groups and women agreed on the importance of the midwife as a guide through labour and birth, and stressed the importance of being in tune with the midwife. The presence of the midwife in the room was reassuring for most women, although there wasn’t always a need for her to be active or instructive, but simply to be there. Confirmation and support from the midwife strengthened the woman’s own ability to stay in control and, at the same time, enabled her to relax. Other women were unconcerned about the midwife and were convinced that they would have managed on their own. The guidance of the midwife was essential if complications or difficulties occurred during birth.

I do not remember what they looked like or their names. At my first birth there was this old, very sweet midwife, but I could have been alone in the room. The staff was of no importance for me. (Third child, vaginal birth)

Afterwards when I thought about it, this midwife made the atmosphere in the room so very nice and cozy even when they had to remove the placenta and I had anesthesia and all that, I felt very positive about the birth. (Second child, vaginal birth)

The meaning of a very positive birth experience varied between women, where some women felt their own ability was the main factor and others describing the importance of support and help from the partner, the midwife and/or other staff involved. The citation below illustrates a general attitude in the focus groups. Women’s stories and the discussions about the meaning of a very positive birth experience focused on the birthing process. Still, it was understood and discussed as a matter of course that the birth of a child and becoming a mother was the foremost and central experience.

Yes, I just want to agree with you, the meaning of it all was the baby. And the treatment was good, but the best I think was that I was part of it, I was prepared and had made up my mind that it would be fine this time. (Second child, vaginal birth)

This study showed that women related their very positive birth experience to internal factors, such as their own ability and strength, as well as external factors, such as a trustful and respectful relationship with the midwife. A woman’s sense of trust and support from the father of the child was also important. The feeling of safety promoted by a supportive environment was essential to gaining control during birth and focusing on techniques enabling women to manage labour.

A variety of expressions were used in women’s birth stories to describe their very positive experiences. These expressions reflected a significant moment in the women’s lives, where feelings of joy and happiness dominated. Crowther et al. [ 14 ] studied the experience of joy at birth from a hermeneutic perspective and concluded that, although the literature on women’s birth experiences is extensive, it rarely focuses on joy. There is therefore a need to explore experiential aspects of birth beyond the type, place and outcome of the birth. The present study reports profound and reflective experiences narrated by the women and further developed along the discussions in the focus groups.

The women’s experience of their ability and strength was one of two overarching themes in this study. Birth specific domains most relevant for women’s overall experience have been identified that relate to this result. Seven domains were described in a mixed-method design study that included literature review, focus groups and consensus discussions with women and professionals [ 15 ]. The authors propose that the availability and quality of received care, concerns about safety, the first contact with the newborn, and health of the baby are key aspects for a mother’s overall birth experience. Further, the domain related to the health professional’s behavior and attitudes, as well as women’s feelings of confidence and safety, are of more importance than the course of labour, or the medical and environmental aspects of the birth. These findings are in line with the results of our study, where women were convinced that they would manage the challenges of giving birth. Maternal confidence e.g., a woman’s confidence in her ability to cope has been acknowledged in research. Self-efficacy can be defined as the confidence a person feels about performing a particular task [ 16 ]. Related to childbirth, Lowe [ 17 ] developed the Childbirth Women Self-efficacy Inventory, which has been used in several studies [ 18 , 19 ]. Woman with increased self-efficacy experience less fear and pain and more satisfaction with birth compared to women with low self-efficacy.

Feelings of confidence and its relevance for positive expectations were clearly important among women in the focus groups. The fulfillment of expectations has been shown to be the most consistent determining factor of satisfaction with childbirth. The self-esteem of the woman, sense of accomplishment, and confidence as a new mother is further enhanced by positive perceptions and satisfaction with the birth experience [ 7 , 20 ].

It is well known that women’s sense of control during childbirth is related to a positive birth experience [ 21 , 22 ]. In a concept analysis, Meyer [ 23 ] identified four attributes of control in childbirth: decision-making, access to information, personal security, and physical functioning. This is consistent with the results of this study, and these aspects of a positive birth experience were all discussed in the focus groups. Women mostly described control in relation to bodily function and pain. Their ability to handle pain and other difficulties was a source of satisfaction that contributed to their positive experience. Women expected to be informed about the progression and other matters of importance; taking part in decision-making was discussed as natural unless it was an emergency situation. The meaning of control was mostly identified as an internal capacity, that is, the ability to maintain control over the behavior and the body. Other women talked about their experience of having influenced the atmosphere in the room and the behavior of the midwife, which can be considered external control [ 24 ]. The experience of control made it easier for the women in labour to turn their focus inward, letting go of the outside world. This was difficult unless women felt that they had taken command of the birth and this can be interpreted as maintaining control so as to avoid ‘losing oneself’ [ 25 , 26 ].

Trustful and supportive relationships were essential for a positive birth experience. It was clear that the presence of the midwife was important even if the woman felt capable and did not explicitly need help and support from the midwife. The midwife and the assistant nurse ensured feelings of safety and calm for the birth mother, and the significance of these relationships with caregivers is evident in research [ 27 , 28 ]. A systematic review [ 28 ] identified four key factors essential for women’s satisfaction with birth, with two of these being directly related to the mother-caregiver relationship: the quality of the relationship between the birthing mother and the caregiver; and the amount of support the woman received. The attitude and behavior of the caregivers expressed in the relationship with the woman outweighed the effects of all other variables (e.g., age, birth environment and medical interventions). Hunters’ study [ 29 ] on women’s experiences of birthing with doulas is of interest. Interviews with nine doulas and nine mothers revealed that the doulas, as paraprofessionals, were “holding the space”. This birthing space for women was created by components mentioned as crucial in the focus group’s discussions; the practical techniques and methods, the relationship, and the physical and emotional support. The mother-caregiver relationship with the midwife helped some women achieve an intimate space within an institutionalized birth and this was typically very much appreciated. Almost all births in Sweden take place in a hospital, which has become the natural and culturally accepted place to give birth, with only a few available alternatives (e.g., midwifery-led birth centers or home birth). It is crucial that a beneficial and supportive environment can be established within the walls of a medicalized maternity care.

The relationship with the father of the child was identified as another partnership of great importance for the women. Most women agreed that it was essential to have their partner close. The father effectively acting as a guard in the birthing room; well aware of the wishes and needs of the woman. Previous research demonstrates the importance of partner’s support on women’s birth experience. Among 325 Finnish first-time mothers, the attitude of the child’s father toward pregnancy was one of three predictors for a positive birth experience [ 30 ]. The partner’s support during birth was described as critical in helping women cope with labour by providing encouragement and reassurance [ 31 ]. Women in the focus groups described being part of a team, where all participants were significant for the birth experience.

This study is a further example amongst the literature showing that it is difficult to separate the birth experience from the care given [ 32 ]. Focusing solely on the experience will overlook the birthing environment and overlook the synergistic effect of a caring and reassuring midwife working together with the woman and her partner. In a recent study, women who stated that they were looked after very well and had a very positive birth experience were significantly more likely to have experienced high postnatal functioning [ 33 ]. This again highlights how it is possible to enhance a positive birth experience by developing maternity care customized to deliver what women want.

A principal strength of this study is its longitudinal design, where women first assessed their birth as very positive and then participated in focus group discussion six to seven years later, entering more deeply into the experience. To our knowledge, this has never been previously reported. All women had accurate and vivid memories of their birth. It is well known that women clearly remember their birth experience [ 34 ]. The decision to use focus groups for data collection proved accurate and effective, with all women taking an active part in the discussions.

However, the findings are limited to the data collected during seven focus groups in a Swedish setting. The participating women are a relatively homogenous group, which might have influenced the discussions. The timing of recruitment, 6–7 years after the index birth assessed as a very positive birth experience, is also of importance. Women who responded to the invitation had an interest in birthing experiences and a willingness to share them with others, despite the years that had passed, which might differentiate them from other women. It is difficult to generalize the findings, but we suggest that the result of the study may be transferable to other birthing women in a similar context. The interaction with and support from the birth partner and other caregivers is most likely a universal experience. The judgment of trustworthiness in the study should be based on transferability, credibility and dependability [ 35 ]. The presentation of data, the process of analysis, and the quotations from the transcripts confirm the credibility of the study. Dependability was established through ongoing discussions between the authors where agreements were made on the interpretation of data.

It is an essential part of midwifery care to build relationships with women where mutual trust in one another’s competence is critical. The midwife is the active guide through pregnancy and birth and expresses a strong belief in a woman’s ability to give birth. Midwives are required to inform and encourage women, and to provide tools to overcome the challenge of birth. It is important for midwives to invite the partner to be part of a team in which everyone works for the best interest of the woman and child.

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Karlström, A., Nystedt, A. & Hildingsson, I. The meaning of a very positive birth experience: focus groups discussions with women. BMC Pregnancy Childbirth 15 , 251 (2015). https://doi.org/10.1186/s12884-015-0683-0

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• http://orcid.org/0000-0002-9614-9496 Ibone Olza 1 ,
• Patricia Leahy-Warren 2 ,
• Yael Benyamini 3 ,
• Maria Kazmierczak 4 ,
• Sigfridur Inga Karlsdottir 5 ,
• Andria Spyridou 6 ,
• Esther Crespo-Mirasol 7 ,
• Lea Takács 8 ,
• Priscilla J Hall 9 ,
• Margaret Murphy 2 ,
• Sigridur Sia Jonsdottir 10 ,
• Soo Downe 11 ,
• Marianne J Nieuwenhuijze 12
• 1 Faculty of Medicine , Universidad de Alcala de Henares , Alcala de Henares , Madrid , Spain
• 2 School of Nursing & Midwifery, University College Cork , Cork , Ireland
• 3 Bob Shapell School of Social Work, Tel Aviv University , Tel Aviv , Israel
• 4 Institute of Psychology , Uniwersytet Gdanski , Gdansk , Poland
• 5 School of Health Sciences , University of Akureyri , Akureyri , Iceland
• 6 Department of Psychology , Universitat Konstanz Fachbereich Psychologie , Konstanz , Baden-Württemberg , Germany
• 7 Hospital Clinic , University of Barcelona , Barcelona , Spain
• 8 Department of Psychology, Faculty of Arts , Charles University , Prague , Czech Republic
• 9 Emory University. Nell Hodgson Woodruff School of Nursing , Atlanta , USA
• 10 School of Health Science , University of Akureyri , Akureyri , Iceland
• 11 University of Central Lancashire , preston , Lancashire , UK
• 12 Research Centre for Midwifery Science , Zuyd University , Maastricht , The Netherlands
• Correspondence to Dr Ibone Olza; iboneolza{at}gmail.com

Objective To synthesise qualitative studies on women’s psychological experiences of physiological childbirth.

Design Meta-synthesis.

Methods Studies exploring women’s psychological experiences of physiological birth using qualitative methods were eligible. The research group searched the following databases: MEDLINE, CINAHL, PsycINFO, PsycARTICLES, SocINDEX and Psychology and Behavioural Sciences Collection. We contacted the key authors searched reference lists of the collected articles. Quality assessment was done independently using the Critical Appraisal Skills Programme (CASP) checklist. Studies were synthesised using techniques of meta-ethnography.

Results Eight studies involving 94 women were included. Three third order interpretations were identified: ‘maintaining self-confidence in early labour’, ‘withdrawing within as labour intensifies’ and ‘the uniqueness of the birth experience’. Using the first, second and third order interpretations, a line of argument developed that demonstrated ‘the empowering journey of giving birth’ encompassing the various emotions, thoughts and behaviours that women experience during birth.

Conclusion Giving birth physiologically is an intense and transformative psychological experience that generates a sense of empowerment. The benefits of this process can be maximised through physical, emotional and social support for women, enhancing their belief in their ability to birth and not disturbing physiology unless it is necessary. Healthcare professionals need to take cognisance of the empowering effects of the psychological experience of physiological childbirth. Further research to validate the results from this study is necessary.

PROSPERO registration number CRD42016037072.

• physiological childbirth
• lived experiences
• pyschological
• empowerment

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2017-020347

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Strengths and limitations of this study

Strict inclusion criteria were applied so that only studies where all women had unmedicated births were included.

Some births had occurred more than 10 years before. Parity was not differentiated as a criteria.

All selected studies came from high-income countries.

All births were attended by midwives and a relatively large number of women included in this study had a home birth.

Introduction

Childbirth is a profound psychological experience that has a physical, psychological, social and existential impact both in the short and long term. 1 It leaves lifelong vivid memories for women. 2 The effects of a birth experience can be positive and empowering, or negative and traumatising. 3–5 Regardless of their cultural background, women need to share their birth stories to fully integrate an experience that is both physically and emotionally intense. 6

Neurobiologically, childbirth is directed by hormones produced both by the maternal and the fetal brain. 7 During childbirth and immediately after delivery, both brains are immersed in a very specific neurohormonal scenario, impossible to reproduce artificially. The psychology of childbirth is likely to be mediated by these neuro-hormones, as well as by particular cultural and personal issues. The peaks of endogenous oxytocin during labour, together with the progressive release of endorphins in the maternal brain, are likely to cause the altered state of consciousness most typical of unmedicated labour that midwives and mothers easily recognise or describe as ‘labour land’, but this phenomenon has received little attention from neuropsychology.

Midwives and obstetricians require a deep understanding of the emotional aspects of childbirth in order to meet the emotional and psychosocial needs of labouring women. Factors that facilitate a positive birth experience include having a sense of control during birth, an opportunity for active involvement in care and support and responsive care from others in relation to women’s experience of labour pain. 8–10 There is limited research on women’s lived experience of physiological childbirth, including their emotional response. 11–13 This lack of knowledge concerning the psychological dimension of childbirth can lead to mismanagement of the birthing process. At the extreme, a lack of understanding of the psychology of childbirth can contribute to a traumatising birth, which can be devastating to women even when the immediate outcome is a physically healthy mother and newborn. 14 When women in labour encounter caregivers who do not incorporate emotional needs into their care, they can experience this as disrespect, mistreatment or in some instances, as a form of abuse 15 or obstetric violence. 16 The problem of disrespect towards women in labour is a growing concern globally, as is also the over-application of medicalised care practices for healthy women. 17–19 Rates for these interventions vary greatly between and within countries. For example, using 2010 Euro-Peristat data, Macfarlane et al 17 (2016) reported on a range in spontaneous vaginal birth from 45.3% to 78.5%. 20

The medical model has traditionally divided labour into stages according to mechanical or physical changes such as dilation of the cervix and descent of the head as depicted on the traditional Friedman’s curve or WHO partograph. 21 However, the subjective, emotional experience of labour does not conform to these mechanical descriptions of the body’s changes. It is questionable that women experience specific stages or phases as traditionally described by professionals. 22 Understanding the psychological experience in physiological childbirth can contribute to enhancing a salutogenic approach to health and can contribute to the promotion of healthy, happy family relationships in the longer term.

The aim of this meta-synthesis is to locate and synthesise published qualitative studies that describe the psychological process of women during physiological childbirth, paying attention to the immanent psychological responses that emerge during the process of labour and birth. We hypothesised that there is a common psychological experience of physiological labour. We focus on labouring women’s thoughts and feelings, and the meanings they ascribe to their perceptions of childbirth process and the surrounding environment, as reaction to both childbirth and to the surrounding environment are part of a single psychological process. We refer to the psychological process in terms of the ‘lived experience’ and thus we adopted a Husserlian a phenomenological approach for the analysis of the data in the included studies.

We undertook a meta-synthesis. This is a process of reviewing and consolidating qualitative research, to create a summary of qualitative findings and allow for the development of new interpretations (Thomas and Harden, 2008). Qualitative synthesis of a number of qualitative studies provides robust evidence to inform healthcare practices. Meta-ethnography was deemed the most appropriate qualitative synthesis approach for this analysis in order to transcend the findings of individual study accounts in developing a conceptual model. 23 This synthesis method has the potential to provide a higher level of analysis and generate new conceptual understandings. 24 The research approach used for this meta-synthesis was the seven-step process described by Noblit and Hare, 25 26 which uses meta-ethnographic techniques like reciprocal and refutational techniques as well as line of argument synthesis. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements to inform the meta-synthesis. 27 The research protocol was registered and published in the International Prospective Register of Systematic Reviews. 28

Patients and public were not involved in the design, conception or conduct of this study.

Data sources

A systematic search was conducted in March 2016 and updated in October 2017. The following databases were included: EBSCOhost, including the database MEDLINE, CINAHL, PsycINFO, PsycARTICLES, SocINDEX and Psychology and Behavioural Sciences Collection. The search terms are given in online  supplementary appendix 1 . (We used EBSCOhost for the complete search and therefore did not use MeSH terms.) Eligible papers were written in English, Spanish and Portuguese. Five groups of two authors independently read the abstracts and selected the articles, and the decision to include an article was achieved by consensus. When there was disagreement, a third author provided assistance and input. We searched reference lists of the included articles to identify additional articles that were relevant to the study question. We sought suggestions from experts in the field and articles from other sources.

Supplementary file 1

Eligibility criteria for selecting studies.

For the purpose of our study, physiological childbirth was defined as an uninterrupted process without major interventions, such as induction, augmentation, instrumental assistance, caesarean section as well as use of epidural anaesthesia or other pain relief medications. The inclusion criteria were (1) original research of (2) women who had physiological childbirth and (3) described their experiences and behaviours during (4) the whole process of childbirth. Studies were excluded, if the experience of childbirth was (1) described by any source other than the woman who experienced the birth (eg, from healthcare professionals), (2) described only a single stage in the birth process or (3) described births with major medical and surgical interventions (or pain management (eg, caesarean section).

Data extraction and synthesis

Data analysis included the following steps. The first order interpretation involved reading and re-reading all studies to become familiar with their content, feeling and tone. The first author (IO) conducted a line-by-line coding of the findings of all included studies. Quotes, interpretations and explanations in the original studies were treated as data. The coding categories included: feelings, behaviours (actions), signs (eg, pain, contractions), relations (midwife, partner, baby and relatives), time perception, cognitions (thoughts and knowledge) and location (home, water, places, transferring). Based on the emerging data, these coding categories were sorted into (1) early labour, (2) intense labour, (3) pushing, (4) baby out (immediately), (5) placenta and (6) evaluation of the whole birth experience.

To achieve the second and third order interpretation, the research team reflected on the first order interpretations to identify the themes and subthemes that describe the emerging constructs grounded in the primary studies. This process included reciprocal (similarity) and refutational (contradictory) analysis which identified differences, divergences and dissonance between the studies and then to synthesise these translations. Following this reflection process, the research team used a line of argument to create a model that best explains the psychological process of physiological childbirth, as described in the included studies.

Quality assessment

To ensure the quality of the findings in the study, all selected papers were screened on the methodological quality using CASP 29 and subsequently, all the included papers were assessed using consolidated criteria for reporting qualitative research (COREQ) 30 to ensure they had reported all the relevant details of their methodological and analytic approach.

Reflexivity

Throughout the research process, the authors identified and explored their own views and opinions as possible influences on the decisions taken. This was done because of the subjective nature of qualitative research to protect the methodological rigour of the study. All the authors of this paper are part of an EU-funded COST Action specifically examining aspects of physiological birth. The research group have chosen to participate in the COST Action IS1405 Building Intrapartum Research Thorugh Health (BIRTH) because of strong interests in the importance of understanding physiological and psychological processes of childbirth, to enhance the capacity of women to labour and give birth normally where this was possible for them, and where it is their choice to do so. All the authors believe that birth is a profound physiological, psychological and socio-cultural experience for most women and babies.

The research team included authors of multidisciplinary backgrounds. The contribution of each author, coming from different paradigms and perspectives on women’s needs in labour, ensured the interpretation of findings was grounded in the data and came from the data. The use of refutational analyses, as recommended by Noblit and Hare 20 21  minimises the risk of overlooking information because it did not fit with the authors’ pre-conceptions. This strengthens the trustworthiness of this research.

Included studies

The search identified 1520 articles in EBSCOhost. There were 376 duplicates, which were removed, leaving 1144 unique articles in the sample. figure 1 demonstrates the selection process, which resulted in eight included studies. All of the selected studies met the quality screening and assessment criteria. Some papers had to be excluded because just one or a few participants did not have a physiological birth as defined for this study. CASP and COREQ assessments are detailed in the online  supplementary files .

Supplementary file 2

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Flow chart. 

The eight included studies involved 94 women, 28 primiparous and 22 multiparous women, although four studies did not identify parity in their sample. Of these, two studies had a mix of primiparous and multiparous women (half each) 17 27 and two studies did not address parity for the sample at all. 28 29 Most of the interviews took place within a year after birth, but some studies had longer intervals, and in two studies, women were interviewed up to 10 or 20 years after birth. 11 31 One study did not identify a time interval between the index birth and the interview. 32 Thirty-nine of the women gave birth at home, four in a primary care unit and 51 in hospital. It seems that midwives were the primary carers of these women. Further characteristics of the studies can be found in table 1 .

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Characteristics of selected studies 

Meta-synthesis analysis

Three main themes emerged: maintaining self-confidence in early labour, withdrawing within as labour intensifies and the uniqueness of the birth experience. A number of subthemes were identified within each of the three main themes, which are listed on table 2 .

Themes, subthemes and studies contributing.

Maintaining self-confidence in early labour

This theme presents women’s experiences when they realised that they were in labour. The accounts indicated that women knew when they were in labour and most preferred to wait calmly for progress, maintaining confidence by keeping a familiar routine and environment.

Experiencing the start of labour

Women described their feelings when they realised that they were in early labour. Some felt excited and others described a lovely feeling, comparing it to Christmas 13 (p. 372). A mixture of feelings emanated from the data at this time, including excitement, happiness, calm, sometimes mixed with apprehension and anxiety. 3 11 33

Women found it important to conserve their emotional strength and to maintain a positive attitude. 3 11 Some described being happy with staying in their own home, and felt it was important to keep calm:

I felt confident by staying in my own living room ( 3 , p724).

They acknowledged the close and trustful relationships in their network at that time in their life. 3 13 31

Thought it was reassuring to be together with family in familiar surroundings ( 3 , p724).

Sharing the beginning of labour

When women recognised the beginning of labour, they shared it with other women. Usually they called their mother or sister, before calling the midwife or the hospital. 12 13 Few asked their midwife to be with them at this point.

At 10 o’clock in the morning I called the hospital. Of course, I had talked to my mom first ( 3 , p274).

They indicated that it was important for them to know their midwife, because it gave them confidence and trust 3 12 13 32 33

Keeping life normal

The most common behaviour at the onset of labour appeared to be continuing with the usual routine. There were many descriptions of wanting to remain at home, taking a shower, being aware of others’ needs (like older children or even pets) and waiting happily. Their own home with their relatives and partners around them 3 11 33 was a tranquil place to be while their contractions were becoming more intense and the pain was increasing. 3 11

I was lying all night and with my labour pains and my dog came and lay by my feet…it was an incredible feeling, it was in September, all the apples in the trees…it was all so silent… ( 31 , p352).

Withdrawing within as labour intensifies

As the labour intensified, women withdrew into an inner world where time seemed to be suspended. Women described how this inner space allowed them to concentrate on the labouring process, and this facilitated the feeling that they could manage. The experience of control was complex and nuanced—for some, the sense of being in control was directed at making all of the decisions and for others, it was achieved by feeling safe enough to hand over control (or guardianship) to the midwife, so that they could retreat into their inner world of labouring.

Accepting the intensity of labour

When contractions became stronger and pain intensified, women felt the need to be fully focused on the physical task. 13 At this point women really needed to be with safe companions in a protected place. This was the moment to contact the midwife and/or move to the hospital.

I’ve got to be somewhere where I can actually allow myself to feel what I am going through ( 13 , p373).

The pain experience was framed by accepting pain as a natural part of childbirth, and this was important for women. 3 32 Two key elements in the response to pain were trusting in the body and working with pain. 3 11 Mobility was important in this phase, and women needed to move around 32 or submerge themselves in water. 34 The following quote is an example of how women framed the pain experience to reduce fear.

I don’t think it is explained very well what the pain is for. People just get frightened of the pain. If they could see it as something useful…the pain is there so as you can help them out, it’s not frightening at all (p58).

Women described their desire to be in control, but this was different for the individual women. For some, control meant staying on top of things and deciding what they needed, whereas for others, control was the decision to hand over management to the midwives. 34

Not having any experience of labour, I needed the midwife to tell me what to do. Because she was in control I felt I was too’ ( 34 , p33).

Women expressed their need for a caring approach. 3 11 13 34 The support from midwives helped women to face the vulnerability they experienced during labour.

Knowing the midwives so well makes you feel quite at ease, if you are scared and you haven t got anyone reassuring you, you are just panicking, and it hurts a lot more ( 33 , p239).

You are so incredibly vulnerable and I feel that you have such a need that someone is kind to you and shows you some interest. All your energy goes into giving birth to this child and you simply don’t have energy left to argue with someone or make a fuss about something. You almost have to take whatever your surroundings offer you ( 11 , p52).

All throughout she said to me: you are coping fine, Linda; I felt assured. That was how she was making me feel calm all throughout she said to me: you are coping fine, Linda; I felt assured. That was how she was making me feel calm ( 33 , p239).

A woman giving birth is perhaps much most sensitive or vulnerable that when she is not in labour. If for example the midwife or member of the staff hurt her in some way or says something inappropriate, then it drastically offsets your labour ( 11 , p52)

They also described how important their partner was.

I felt he was my lifeline, he had the best analgesic effect on me and he did not leave me once ( 31 , p. 352).

Sometimes they needed to be alone with their partners yet still able to reach their midwife whenever they needed. 33 34

I felt like we were doing it ourselves, which was nice. We didn’t feel we needed the midwife all the time but she was there if we did ( 34 , p34).

Going to an inner world

Women described how they withdrew within themselves to an inner world, where they focused on the importance of living just in that moment. Words used included ‘ narrowed ’, ‘ zone ’, ‘faraway place’, ‘another planet’ and ‘ private ’. 11–13 31

Nothing else matters and the universe kind of shrinks to this particular, you know this particular job that you have to do which is you know about birthing your baby( 13 , p373).

Like with both my labours, I took myself away. I need not to have people looking at me ( 12 , p49).

Women described perceptions of an altered or suspended sense of time.

My sense of time was completely lost, as if I had forgotten it in a drawer at home. It was a very strange feeling. There are a lot of people around you and yet you are in your own world. Even if we were in the same room we were not in the same world…’( 11 , p52).

Over time as the intensity of the contractions and the pain increased, women described feelings of fear and desperation. 13 Some felt exhausted and deprived of energy. 11 32 The thought that they could not continue any more, expressing fears of death. 11

I was so optimistic in the beginning of the latter birth…I had given birth before and I survived…so that you believe you will survive. However, in both births I had this feeling for some time that I would never survive this ( 11 , p56).

I was requesting for a caesarean, I was requesting for everything! Because I just wanted to get over with it. I just said I was going to die. At one point I felt like I was going to faint and stuff like that. I said: ‘Please Sandra, I want pain relief.’ I was actually begging her, ‘Please, please, please.’ I said, ‘I’m going to die! I won’t be able to do this! ( 33 , p239).

Coming back to push

When starting to push, time was no longer suspended and women became more active. 11 13

When I started to push, it was as if a curtain was drawn. A totally different perception, suddenly I was awake, alert and quite aware of timing’ ( 11 , p55).

… I was at the top of the mountain when I started to push. And then I had to get down again. And that was it! ( 3 , p725).

Uniqueness of the birth experience

With the birth of their baby women described relief, joy at meeting their baby and sense of transformation.

Reaching the glorious zenith

Directly after birth, women described feelings of pride and joy in achieving and experiencing natural childbirth. 11 13 32 33

So I was brave, I was strong!… So I was like, ‘Yes, I have done it! Yes, I can do it!’ I was so happy. I honestly never had this kind of joy since I was born. I don’t know where this joy came from. I don’t know how to describe the endless joy that came in me ( 33 , p239).

What is most prominent in the birth experience as a whole is the sense of victory, the feeling of ecstasy when the baby is born. That feeling is unique, and in the last birth I was without all medication and therefore I could enjoy this feeling much better. Well, I enjoyed it completely ( 11 , p57).

Women described the intensity of their feelings of childbirth as being their greatest, unparalleled achievement.

It is an intense experience, a powerful life experience. It is naturally magnificent that you, just to find that you are capable of giving birth, to a child, that you can do it. To be such a perfect being that you can do it…the feeling you get when you get your new born child into your arms naturally is indescribable. It is a feeling you cannot compare with anything else. It is awe inspiring 11 (p56).

Women also expressed feelings of spiritual closeness and gratitude.

I had this holiness, being close to the universe. I feel such gratitude for the possibility to give birth at home ( 31 , p350).

Some women were also surprised and satisfied how effectively their body had taken them through the labour 13 and they were proud of how they managed their pain. This ability to manage labour pain positively influenced their confidence in becoming a mother. 33

I can’t really explain. I’m very pleased, very pleased, that I did it naturally. I feel so proud, full of myself. I am very proud to have him naturally. I am very proud even now.( 33 , p239).

However, as well as being a unique and powerful experience, some women also expressed a need for a sense of peace, and of routine to ground themselves in the new reality of motherhood. 32

Meeting the baby

Women described the speed with which they assured themselves that their baby looked normal.

I remember particularly that as soon as the baby is born you think incredibly fast and you look incredibly fast whether there are, without all doubts, ten toes and ten fingers and everything that is supposed to be in place is there and many other things. 11 (p56).

Women with other children were impatient for them to meet their new sibling. It was important for them to involve other family members soon after birth to share this important moment with them. 32

As soon as I had the baby I’d had my bath and everything and my mum and everybody arrived…we were all in the garden with the baby ( 32 , p58).

Women described a sense of being ‘cocooned’ within the family soon after the baby was born 33 and this was expressed in the manner in which the new baby was welcomed by hugs, kisses and expressions of love. 31

By three o’clock everybody had left except for just ourselves, the four of us, the whole family. We were just tucked up across my bed and I think in some ways that was the moment that felt that this is absolutely right. There’s nothing more right in the world. I was just all so peaceful. So why would do anything differently kind of feeling to it ( 29 , p58).

The birth of the placenta was only mentioned in one study. 19 For some women, it was anti-climactic after the birth of the baby, while others considered it a part of the recovery process.

Empowered self

After processing their emotions, women described feeling different. They absorbed new knowledge and understanding about themselves and incorporated this into their sense of self. They talked about their birth as an empowering experience. 12

…I felt I could sense right then, when minutes passed by. I felt that I (tearful) was a little bit different ( 11 p56).

Women linked their pride about coping with pain to feeling strong and confident and to a positive start to new motherhood. 33

When you do that as a woman, you know you can do anything … I realised how everything else in life is easy, if you can do that (enduring 70 hours of no sleep, wild contractions, etc.) you can do anything. I am sad that so many women don’t get to understand this ( 12 , p52).

The empowering journey of giving birth

Constructing a line of argument is the next step in a meta-synthesis based on the first, second and third order interpretations. For this study, the line of argument demonstrated ‘the empowering journey of giving birth’, encompassing the various emotions, thoughts and behaviours that women experience during labour.

Women’s psychological journey originated with telling other women from their social network that labour had started, while staying cocooned in a familiar environment. Most women focused on maintaining self-confidence at the start of labour and tended to withdraw into an inner world as labour became more intense. As birth progressed, women experienced an altered state of consciousness including a change in time perception and intense feelings such as fear of dying. Women described various ways of coping with the pain and keeping control, which paradoxically, included releasing control to the midwife where appropriate. With the urge to push, women felt that once again they became alert and more active. Immediately after the baby was born, feelings of joy and pride were predominant. The journey through childbirth meant a growth in personal strength. Some women described themselves as a changed person in the sense that they felt stronger, empowered and ready to meet the demands of the newborn.

Our study offers new insights into women’s psychological experience of physiologic childbirth as a meta-synthesis on this topic has not been previously reported. We created a model of the emerging psychological pattern of this journey that is designated in terms of emotions and behaviours. Women described birth as a challenging but predominantly positive experience that they were able to overcome with their own coping resources and the help of others. For them, this resulted in feelings of strength to face a new episode in their life with their family. Our findings confirm our main hypothesis: there is a common psychological experience of physiological labour. As far as we are aware, this has not previously been reported using women’s accounts as primary data. Our findings suggest that birth is just as much a psychological journey as a physical one.

Although the whole event does not seem to have been described before on the basis of qualitative evidence, elements of our findings are coherent with those from other studies. The preference for familiarity of environment and people at the start of birth, 35 the altered state of consciousness, 36 37 the different time perception, 38–40 the empowerment 6 41 42 and change 37 43 that come with childbirth have previously been described.

In our meta-synthesis, overall women expressed confidence in their capacity to give birth and to trust in themselves and in the process, despite some apprehension as labour began, and some concerns, including fear of death, during the most intensive stages of labour. Positive perceptions of their own coping strategies and confidence in their ability to go through birth were linked to women’s positive experience of birth. 44

Women’s psychological experience of physiological childbirth is strongly influenced by the people present at their birth. Women indicated that close relatives, mostly their partner and mother, as well as care providers were highly relevant for the way women experienced their birthing process. Women described the presence of their partner as the person with whom they most closely shared their experience and relied on for support, confirming that human birth is a social event. 45 This is consistent with other studies that emphasised the decisive contribution partners can make to feelings of trust 46 47 and the woman’s wish for a physiological birth. 48

Women indicated the midwife’s presence as being critically important. At the beginning of the labour, women tended to want to be alone and at a distance from the midwife, but, as labour intensified, they wanted the midwife to be more visible and present while supporting the woman’s control, or taking control if women wanted to hand it over. Control was a key feature in our study. Over the years various researchers identified different internal and external dimensions of control. 49 50 Women’s internal control includes a sense of self-control, such as thoughts, emotions, behaviours and coping with labour pain. External control is described as the woman’s involvement in what is happening during birth, understanding what care providers are doing and having an influence on the decisions. What seems important to women is not so much ‘having control’, but rather the affective component of control, which is the ‘feeling’ of having influence, 10 being able to have a say in what happens and having caregivers who are responsive to expressed wishes. Women’s external control also seemed to arise from feeling that they were informed and could challenge decisions if the need arose. 49

Mixed feelings, both positive and negative, were expressed regarding labour pain, and this is similar to several studies. 51 Women experienced pain as meaningful in relation to their baby. They recognised its intensity but reframed it positively. This was also the case for other feelings that are usually interpreted negatively (being exhausted, feeling overwhelmed and fear of dying) that were referred to in relation to specific moments of the labour and birth, but not in the global psychological evaluation of the experience once it was over. Pain and coping with pain also contributed to gaining strength to cope with the demands of parenthood. Berentson-Shaw et al 44 indicated that stronger self-efficacy during birth explains a lower level of pain. 44 Rijnders et al 52 showed that women who felt unsatisfied about their coping with pain had more negative emotions about their birth. 52

What this meta-synthesis demonstrates is the enormous importance of having maternity care providers, including midwives, at the birth that are compassionate and support women to keep a sense of control that is adjusted to their personal needs and wishes. Care providers can strengthen women’s sense of coherence in offering them emotional support, stimulating trust and confidence and supporting meaningful others to be there during the birthing process. Labouring women need to be able to create a trustful bond with the midwives and obstetricians attending them that offers reassurance and enables them to feel in control. It may be that women are more likely to experience a psychologically positive physiological birth when they feel that a supportive and compassionate companion or healthcare provider (in the case of the included studies, a midwife) is by their side, and is very sensitive and attentive to their cues. This includes effective responses when the woman needs them, and simple encouragement, information or support to reassure them that what is happening to them is normal. Such support may enable women to trust that they are safe to focus inwards, which facilitates the release of hormones and enables the maternal behaviours that are essential to progress a physiological labour and birth. Midwives and other caregivers, including obstetricians, can facilitate this process by demonstrating empathy, compassion and supporting a woman’s belief in her own ability to birth. These are key skills and competencies identified in midwifery-led care, recommended to be implemented worldwide. 53 These affective skills should be included in midwifery, nursing and medical education so that all caregivers have the same expertise in the emotional care of women during birth.

Most women in this synthesis indicated that, for them, birth was an enriching experience that gave them confidence in their own strength to face the challenges of motherhood. These emotions may be quite different when women are confronted with unexpected complications during childbirth, such as an emergency referral to obstetric care, an assisted vaginal birth or an unplanned caesarean section, which tend to be associated with more negative emotions. 54 55 Some women experience grief following a traumatic birth (which could include a birth without interventions, especially where women feel discounted, or actively abused). This grieving may well be the mourning over the loss of the experience which contributes to feelings of empowerment. 56

This study has several limitations. Close to half of the women in the sample had a home birth (39 of the 94 women). Women wishing a home birth seem to have less worries about health issues or fear of childbirth, and a greater desire for personal autonomy. 57 Women planning a midwife-led birth also have lower rates of interventions which is also linked to positive experiences in birth. 58

The studies included in this meta-synthesis were from high-income countries. The experiences of women in places with low-resourced maternity care systems may be different. Our sample was small and we lacked information on women’s parity, preparation for birth, specific details of supporting professionals, partners and significant others, which can be of major influence on women’s experience of childbirth.

Further research is needed in women from different cultural backgrounds. Additionally, it is of great importance to gain insight into the psychological experience of birth in women with complications during pregnancy or childbirth. As childbirth is a neurobiological event directed by neurohormones produced both by the maternal and fetal brain, 7 further research needs to address the interrelationship between neurohormones, psychological experience and physiological labour and birth. 59 60

Positive, physiological labour and birth can be a salutogenic event, from a mental health perspective, as well as in terms of physical well-being. The findings challenge the biomedical ‘stages of labour’ discourse and will help increase awareness of the importance of optimising physiological birth as far as possible to enhance maternal mental health. The benefits of this process can be maximised through physical, emotional and social support for women, enhancing their belief in their ability to birth and not disturbing physiology unless it is necessary.

Conclusions

Giving birth physiologically in the context of supportive, empathic caregivers, is a psychological journey that seems to generate a sense of empowerment in the transition to motherhood. The benefits of this process can be maximised through physical, emotional and social support for women, enhancing their belief in their ability to birth without disturbing physiology unless there is a compelling need. Healthcare professionals need to understand the empowering effects of the psychological experience of physiological childbirth. Further research to validate the results from this study is necessary.

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Contributors All authors conceived and designed the study. MN and PL-W organised and conducted the search. IO, PL-W, YB, MNJ, EC-M, AS, MK, LT, MM and SSJ participated in the selection of the relevant articles. IO and EC-M performed the quality assessment of the studies. IO did the data extraction from the studies and drafted the manuscript. IO, PL-W, YB, MNJ, AS, MK, SSJ, SIK, PJH and SD interpreted the results, critically revised the manuscript for important intellectual content, and contributed to and approved the final version. MNJ, SD and PL-W supervised the project. YB, PJH, SD, MK, PL-W, MNJ and IO made the changes and corrections suggested by the reviewers.

Funding Eu cost action is 1405 birth: Building intrapartum research through health ( http://www.cost.eu/COST_Actions/isch/IS1405 ).

Competing interests None declared.

Patient consent Not required.

Ethics approval Ethical approval was not required for this meta-synthesis.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement Additional unpublished data only available with authors.

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Open Access

Peer-reviewed

Research Article

What matters to women during childbirth: A systematic qualitative review

Contributed equally to this work with: Soo Downe, Kenneth Finlayson

Roles Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Research in Childbirth and Health (ReaCH) group, University of Central Lancashire, Preston, United Kingdom

Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

Roles Conceptualization, Funding acquisition, Supervision, Writing – review & editing

¶ ‡ These authors also contributed equally to this work.

Affiliation UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland

Roles Conceptualization, Funding acquisition, Resources, Writing – review & editing

• Soo Downe, 
• Kenneth Finlayson, 
• Olufemi Oladapo, 
• Mercedes Bonet, 
• A. Metin Gülmezoglu

• Published: April 17, 2018
• https://doi.org/10.1371/journal.pone.0194906
• Reader Comments

17 May 2018: Downe S, Finlayson K, Oladapo OT, Bonet M, Gülmezoglu AM (2018) Correction: What matters to women during childbirth: A systematic qualitative review. PLOS ONE 13(5): e0197791. https://doi.org/10.1371/journal.pone.0197791 View correction

Introduction

Design and provision of good quality maternity care should incorporate what matters to childbearing women. This qualitative systematic review was undertaken to inform WHO intrapartum guidelines.

Using a pre-determined search strategy, we searched Medline, CINAHL, PsycINFO, AMED, EMBASE, LILACS, AJOL, and reference lists of eligible studies published 1996-August 2016 (updated to January 2018), reporting qualitative data on womens’ childbirth beliefs, expectations, and values. Studies including specific interventions or health conditions were excluded. PRISMA guidelines were followed.

Data collection and analysis

Authors’ findings were extracted, logged on a study-specific data form, and synthesised using meta-ethnographic techniques. Confidence in the quality, coherence, relevance and adequacy of data underpinning the resulting themes was assessed using GRADE-CERQual. A line of argument synthesis was developed.

35 studies (19 countries) were included in the primary search, and 2 in the update. Confidence in most results was moderate to high. What mattered to most women was a positive experience that fulfilled or exceeded their prior personal and socio-cultural beliefs and expectations. This included giving birth to a healthy baby in a clinically and psychologically safe environment with practical and emotional support from birth companions, and competent, reassuring, kind clinical staff. Most wanted a physiological labour and birth, while acknowledging that birth can be unpredictable and frightening, and that they may need to ‘go with the flow’. If intervention was needed or wanted, women wanted to retain a sense of personal achievement and control through active decision-making. These values and expectations were mediated through womens’ embodied (physical and psychosocial) experience of pregnancy and birth; local familial and sociocultural norms; and encounters with local maternity services and staff.

Conclusions

Most healthy childbearing women want a positive birth experience. Safety and psychosocial wellbeing are equally valued. Maternity care should be designed to fulfil or exceed womens’ personal and socio-cultural beliefs and expectations.

Citation: Downe S, Finlayson K, Oladapo O, Bonet M, Gülmezoglu AM (2018) What matters to women during childbirth: A systematic qualitative review. PLoS ONE 13(4): e0194906. https://doi.org/10.1371/journal.pone.0194906

Editor: Mohd Noor Norhayati, Universiti Sains Malaysia, MALAYSIA

Received: November 28, 2017; Accepted: February 22, 2018; Published: April 17, 2018

Copyright: © 2018 Downe et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: This work was commissioned to the University of Central Lancashire, UK by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Switzerland as part of the evidence base preparation for the WHO recommendations on intrapartum care. The development of the WHO recommendations on intrapartum care was financially supported by USAID. OTO, MB, and AMG are paid staff of the Department of Reproductive Health and Research, World Health Organization. SD and KF are members of Research in Childbirth and Health (ReaCH) group, University of Central Lancashire, UK. The manuscript represents the views of the named authors only. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Optimum outcomes for pregnant women and their babies depend on acceptable, affordable, accessible, high quality provision of maternity care during pregnancy, childbirth, and the postnatal period [ 1 ]. However, the overuse of interventions in some contexts, and the underuse in others [ 2 ], along with growing evidence of disrespectful and abusive behaviors in some institutional settings [ 3 , 4 ] demonstrates that many maternity services are not meeting these standards. Good quality intrapartum care is vital, both for women and babies who are healthy, and for the minority who experience complications. Basing maternity service design and care provision on what women want and need is essential to maximize uptake of, and continuing access to, service provision [ 5 ]. If local maternity care provision is limited, women may report that they are satisfied, even if they have had poor quality care, as they will not be aware of any better alternatives. Finding out what matters to women about labour and birth (rather than only asking about their actual experiences of intrapartum care) offers the potential to establish what women value, irrespective of what is actually on offer. This could provide a basis for service improvement, locally, and internationally.

Transformational health care, as envisioned by the Global Strategy for Women’s, Children’s and Adolescent Health [ 6 ], requires maternity services to go beyond survival during childbirth. Understanding what outcomes are important to women is critical to developing clinical guidelines and policies that are women-centered, and that are more likely to ensure that women, babies and families thrive as well as survive following childbirth, with the ultimate aim of positive transformation of their lives, and those of their families and communities, in the short and longer term. The objective of this review was, therefore, to explore what matters to healthy women in relation to labour and birth. The findings have informed the framing and development of WHO intrapartum guideline recommendations, and the scope of outcomes to assess optimal intrapartum maternity care in future.

We conducted a systematic qualitative review in accordance with the PRISMA guidelines (See S1 Table for PRISMA Checklist). We included studies where the focus was on healthy pregnant women, who are the majority of those accessing intrapartum care around the world. Study assessment included the use of a validated quality appraisal tool [ 7 ]. Meta-ethnographic techniques [ 8 ] were used for analysis and synthesis, and GRADE-CERQual [ 9 ] was applied to the resulting themes.

Reflexive note

In keeping with quality standards for rigor in qualitative research [ 7 ] the review authors considered their views and opinions on intrapartum care as possible influences on the decisions made in the design and conduct of the study, and, in turn, on how the emerging results of the study influenced those views and opinions. All authors believed at the outset that most maternity care around the world is currently designed to maximize efficiency and to manage risk through precautionary interventions, with less emphasis on the experience of labour and birth for the mother, baby, and attending birth companions. All believed that positive labour experiences are important for the wellbeing of the mother, baby, and the family, in the short and longer term. Refutational analytic techniques [ 8 ] were therefore used to minimize the risk that these pre-suppositions would influence the analysis and the interpretation of the findings.

Search strategy

An example of the search terms used is given in Fig 1 .

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https://doi.org/10.1371/journal.pone.0194906.g001

In summary, the search terms were run in four broad strings covering population, intervention, outcome, and study type, with a view to capturing a wide selection of relevant studies. The terms were developed following a number of a priori scoping exercises across several databases. Where possible, relevant qualitative research limiters were used (e.g. Clinical Queries—Qualitative: Best Balance) to ensure that searches for qualitative studies were optimized. In instances where preliminary searches generated more than 3000 hits the Boolean operator ‘NOT’ was used to exclude studies that were unlikely to relate to the topic of interest. For example, NOT breastfeeding or breast-feeding or diabet* or contracepti* or HIV or anomol* [Ti,Ab]

Inclusion/Exclusion criteria

No language restrictions were applied. Titles and/or abstracts of potentially relevant studies published in languages other than English were initially translated using a basic translation package (Google Translate). If this process suggested the study would be relevant, the full text was translated in detail by bi or multi-lingual colleagues at The University of Central Lancashire (UCLan) or the World Health Organization (WHO).

Studies published before 1996 were excluded, to ensure that the findings reflect the current generation of women who encounter modern intra-partum care. Only studies where the main focus was the beliefs and expectations of women about labour and childbirth (and not studies where the intent was to collect reflections on intrapartum services actually provided) were included. Studies were included if they reported on women’s views directly (and not through staff or partner opinion, or observational data), and where the views were of the general population of healthy women. Studies were excluded if they focused on a particular intervention (e.g epidural use) or procedure (e.g. episiotomy) or represented the views of specific subgroups of women with particular health problems (e.g. obesity, diabetes, pre-eclampsia, etc;). The views of women who were expecting to have a caesarean section for clinical reasons were also excluded.

KF screened the initial hits against the inclusion criteria and referred any queries to SD for discussion. Abstracts and full text papers were included based on consensus between KF and SD.

Data sources

We searched the following databases: Medline, CINAHL, PsycINFO, AMED, EMBASE, LILACS (for studies conducted in South America) and AJOL (for studies conducted in Africa). Searches were conducted between 25 th July and 4th August 2016. Reference lists of included papers were scrutinized (backchained) and included as appropriate. Zetoc alerts were set up for over 50 relevant journals. Details of included papers were logged on a study specific excel file. An updated search was carried out for papers published between August 2016 and January 2018. The results were used as a confirmability check for the original findings.

Quality assessment

The included studies were subject to quality appraisal using the instrument developed by Walsh and Downe [ 7 ] and modified by Downe et al [ 10 ]. This is a simple appraisal system that rates studies against 11 criteria, and then allocates a score from A-D to each study, based on the extent to which it demonstrated credibility, transferability, dependability, and conformability.

Studies scoring D (‘Significant flaws that are very likely to affect the credibility, transferability, dependability and/or confirmability of the study’) were excluded on quality grounds. [See S1 Appendix for details of Quality Assessment]

Analytic strategy

The analytic process followed the method of Noblitt and Hare [ 8 ], which is derived from the constant comparison method [ 11 ]. In step one, the included papers were examined, and an index paper was selected, chosen to best reflect the focus of the review [ 12 ]. The themes and findings identified by the authors of this paper were entered onto a spreadsheet, to develop an initial thematic framework. The findings of all the remaining papers were then mapped to this framework, which continued to develop as the data from each paper were added [ 13 ]. This process includes looking for what is similar between papers (‘reciprocal analysis’), and for what contradicts (‘disconfirms’) the emerging findings (‘refutational analysis’). For the refutational process, as we added each included paper to the analysis, we consciously looked for data that could disconfirm our emerging themes, or our prior beliefs and views related to the topic of the review. If any disconfirming data were found, the themes were amended, so that they continued to capture all the data from the papers we had already analyzed, as well as taking account of the new insights. This process also ensured that the final analysis had high explanatory power for all the data. [See S1 Appenedix for details of thematic development]

The themes were all agreed by consensus between KF and SD, and subject to appraisal by all members of the review team. All were directly derived from quote material in more than one of the included studies. They were assessed for confidence in the quality, coherence, relevance and adequacy of the data contributing to them using the GRADE-CERQual tool [ 9 ]. This is a recently developed instrument, derived from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach used in quantitative effectiveness reviews. The GRADE-CERQual assessment results in a final classification of confidence in the theme in four categories: ‘high’, ‘moderate’, ‘low’ or ‘very low’. [See S1 Appendix for details of CERQual assessments]

All the themes were translated (or synthesized) into a ‘line of argument synthesis’ [ 8 ], based on theoretical concepts that explained the data at a conceptual level. The line of argument is more than the sum of the parts of the review. A robust line of argument has high theoretical transferability beyond the particular included studies, and so it is likely to be applicable in a wider range of settings and circumstances. The line of argument formed the basis for a Statement of Findings that was then used to inform the ‘values’ component of the Evidence to Decision frameworks used as the basis of the development of the WHO Intrapartum Care guideline (2018).

Included studies

The primary search strategy generated a total of 5350 hits, including 10 already known to the authors. Twenty-three duplicate studies were removed, leaving 5327 to be screened. 5217 of these studies were excluded by title or abstract, primarily because they were deemed to be unrelated to the topic of interest. The remaining 110 were taken forward for full text review. A further 71 were excluded at this stage. The reasons for exclusion are shown in Fig 2 .

https://doi.org/10.1371/journal.pone.0194906.g002

Of the 39 full text papers, four were excluded after quality appraisal [ 14 – 17 ]. Two were relatively small Brazilian studies with little or no methodological information [ 14 , 15 ], one was a mixed methods review with limited qualitative data [ 16 ] and one had limited methodological information[ 17 ]. Thirty five papers were included in the final analysis. Post-hoc examination of the four papers excluded on quality grounds indicated that inclusion of the data within them would not have changed the final themes, line of argument, or Summary of Findings statement.

There were no additional studies from the Zetoc alerts.

The updated search generated 26 hits (after screening by title) and a further 2 studies were identified [ 18 , 19 ].

Characteristics and quality of included studies (primary search).

The characteristics and quality of the 35 included studies were tabulated, and are summarized in Table 1 .

https://doi.org/10.1371/journal.pone.0194906.t001

The date range of publication for the results of the primary search was 1996–2015. All regions of the world were represented. By continent, the largest number of studies were based in Europe (n = 9) [ 20 – 28 ] , (UK x3, Sweden x2, Finland, Iceland, Norway, Turkey), and Asia (n = 9) [ 29 – 37 ], (China x2, India x2, Nepal x2, Bangladesh, Kazakhstan, Thailand). Six were from South America [ 38 – 43 ], (Brazil x4, Chile, Ecuador), four from North America [ 44 – 47 ], (Canada x2, USA x2), four from Australasia [ 48 – 51 ] and three from Africa [ 52 – 54 ], (Ghana x2, Kenya).

Most data were collected by individual interviews and/or focus or discussion groups. The papers incorporated a range of methodological approaches from relatively small phenomenological studies, to qualitative analysis of free text survey responses. They represented the views of more than 1800 women, from a wide range of ethnic backgrounds, ages (14–49) and socio-demographic groups. The quality was mostly moderate to high (B or above).

The eligible papers from the updated search were scrutinised to assess similarities or differences between the results generated from the primary review, and the themes and findings in the more recent studies.

Table 2 presents the themes emerging from the synthesis of the data, along with codes, subthemes, and related quotes from the included studies, and the GRADE-CERQual rating of the sub-themes (‘evidence statements’). The numbers used in this table are indexed to the appropriate study in superscript in the reference list below.

https://doi.org/10.1371/journal.pone.0194906.t002

The findings suggest that, with high or moderate confidence, most women around the world hope for a labour and birth experience that enables them to use their inherent physical and psychosocial capacities to labor and give birth to a healthy baby in a clinically, culturally, and psychologically safe environment with continuity of practical and emotional support from a birth companion(s), and with kind, sensitive clinical staff, who provide reassurance and technical competency. Most women place a high value on their capacity to give birth physiologically (expressed variously as ‘normal’ or ‘natural’, or without technical or pharmacological interventions) for the short and longer term physical and psychological wellbeing of themselves, their baby and their family; however, they also acknowledge that birth can be an unpredictable and potentially frightening event, and that they may need to ‘go with the flow’. Even where intervention is needed or wanted, women usually wish to retain a sense of personal achievement and control by being involved in decision making.

This is summarized in three overarching themes: Hoping for a positive birth experience : anticipating triumph and delight , fearing pain and abandonment ; the enduring influence of familial and socio- childbirth norms; and Enacting what matters in the context of what is available .

These themes generated the following line of argument:

For most childbearing women across the world, there is inherent value in being able to use one’s own physical and psychosocial capacities to labour, and to give birth to a healthy baby, even when the process is unpredictable and painful. Beliefs about what matters to women are influenced by familial experiences, and local cultural norms and values. The capacity for women to enact what matters to them is affected by anticipated or actual encounters with maternity care staff and services, including the use of desired, required, and/ or feared childbirth interventions.

The themes and findings in the papers included in the updated search confirmed the review findings, suggesting that the analysis is robust, and theoretically transferable to a range of women and settings around the world.

For most of the respondents in the included studies, childbirth was an important experience, which had characteristics of what has been termed ‘liminality’: the transition stage between one state and another during a life-changing rite of passage [ 55 ]. For a small minority, childbirth was simply a physical process that should be conducted as quickly and painlessly as possible. As with other life-transition experiences, many women were fearful in anticipation of the hard work, pain, and uncertainty of labour, but most of them accepted these (potentially extreme) difficulties as part of the necessary process of achieving a positive, or even transformatory, birth experience for themselves and for their baby. Whatever they thought about the nature of birth, women interpreted their expectations of what could and should happen through the lens of family birth stories, and cultural and social norms. Whether women wanted birth over as quickly and painlessly as possible, or whether they understood it as fundamental to their transition to motherhood, they recognized the potential vulnerability of themselves and their baby through the process, and the essential uncertainty about what might happen. This was associated with a strong desire for safe, supportive, kind, respectful and responsive care during labor and birth. These characteristics applied to birth companions, professional and lay care givers, and to the processes and environment of care. The extent to which women could experience what mattered to them was mediated by the nature of the local maternity care provision that was available to them, including the attitudes and behaviours of staff, the quality of the relationship between women and care providers, and the resources and atmosphere of the local facility.

To our knowledge, this is the first meta-synthesis of what matters to women for labour and birth, as opposed to studies of women’s experiences once they have been through the process. Systematic reviews are inevitably dependent on the nature and quality of data that have already been collected and reported. In reviews of qualitative studies, these data have already been interpreted through the lens of what is seen to be important by the primary authors. Too few studies, from too narrow a cultural context, can limit the external transferability of the findings. Although the intent was to only include studies that reported on womens’ a priori views and expectations about what matters to them for labour and birth, independent of any intrapartum care they may have received, in some cases participants views were inevitably informed by their actual experiences.

However, the findings are strengthened by the inclusion of a large number of studies, covering every region of the world, and by the confirmatory analysis carried out as a result of the updated search.

The use of translation software at the inclusion stage of the review could theoretically have led to the exclusion of some relevant papers. In the event, 4 studies (from the primary search) that were included as a consequence of software translation were in languages other than English (3 in Portuguese and 1 in Japanese). The findings of all of these papers were translated by fluent speakers of the relevant language, and they were consistent with the papers written in English. The final analysis was consistent for women in all regions of the world. GRADE-CERQual assessments indicated that confidence in most of the findings was moderate or high, reflecting the quantity and quality of the included studies, and the wide range of settings, viewpoints, and study types included.

The findings largely reinforce the prior beliefs of the authors, which could suggest that different reviewers might have come to different conclusions. However, this risk was limited by the conscious search for disconfirming data to test the emerging codes, subthemes, and main themes.

The findings apply directly to healthy women of a range of parity, and in a range of cultural and economic settings, who are receiving routine intrapartum care. The review did not include studies that were only focused on women with specific health conditions, such as HIV or diabetes, or women from particular marginalised groups, such as those seen as ethnic or cultural outsiders, or very young or very poor women. However, women from some of these groups were part of the respondent sample in some of the included studies, and individual studies of the views of women who are marginalised suggest that the review findings are highly likely to be transferable [ 56 – 59 ].

Facility birth is generally accepted as a solution to persistently high rates of maternal and neonatal mortality and morbidity. However, since Bowser and Hill published their analysis of disrespect and abuse in institutional birth settings, in 2010 [ 60 ], there has been an increasing recognition that, while providing central facilities for maternity care is necessary for the provision of care to women and/or babies with complications, this strategy is not sufficient to ensure optimal outcomes for all women and babies [ 3 ]. Recent WHO antenatal guidelines incorporate evidence from qualitative systematic reviews, indicating that women value the psychological, cultural and emotional experience of pregnancy as well as the health of themselves and their growing baby [ 61 , 62 ]. These reviews have also revealed that women experience pregnancy, birth, and the postnatal period as a psychological and physical continuum, and not as three distinct and un-related states. The current review adds to this body of evidence, by linking what women perceive as a positive labour and birth to local familial and cultural norms that shape the way that childbirth is framed, and by expressing the limitations on how far women believe they can actually enact a positive experience of labour and birth, depending on the available maternity care provision locally.

The findings support the multiple domains of the Lancet Quality of Maternal and Newborn Care Framework [ 5 ], and of the 2015 WHO Quality of Care Framework for Maternal and Newborn Health [ 1 ]. The former takes a human rights perspective, and incorporates a systematic review of what women want and need. The framework recognizes the importance of safe, accessible, evidence based, respectful care provision, and is based on a philosophy of care that optimizes physiological, psychological and cultural norms and values. The latter links the experience of care with provision of care, evidence based practices for routine care and management of complications, actionable information systems and functional referral systems, as well as competent and motivated human resources and essential physical resources.

The findings of this review also complement the Cochrane effectiveness reviews on midwife-led continuity of care [ 63 ] and continuous support in labour [ 64 ]. The finding that most women would prefer not to have labour interventions unless they are necessary for the safety of their baby and/or themselves is reinforced by the recent Lancet Maternal Health series, in which the excessive over-use of intrapartum interventions in both HIC and LMIC countries is shown to be potentially as serious a problem at the population level as the lack of availability of such interventions when they are life-saving [ 2 ].

This review demonstrates that what matters to women in relation to childbirth is underpinned by three phenomena; the physical and psychosocial narture of birth as an embodied experience; local familial and socio-cultural norms that legitimate or reframe expectations about labour and birth; and how maternity care provision enables or restricts what matters. Whether women perceive childbirth to be a transformatory process that has meaning for them and their baby in the short and longer term, or whether they see it as a necessary process that should be completed as quickly and painlessly as possible, maternity services need to be responsive to their values, beliefs, and needs. What matters to women is also what is likely to generate the safest and most humanized maternity care provision, for mother, baby, and the family. There is now sufficient evidence from a wide range of sources to suggest that it is imperative that maternity services recognize the benefits of providing what matters to women (and the risks of not doing so). Crucially, these factors should become a central component of care provision as a matter of urgency to ensure the optimum uptake of effective and respectful maternity care, and, as a consequence, the health of childbearing women and their babies and families, in both the short and longer-term.

Supporting information

S1 appendix. quality assessment, data extraction and cerqual grading..

https://doi.org/10.1371/journal.pone.0194906.s001

S1 Table. PRISMA checklist.

https://doi.org/10.1371/journal.pone.0194906.s002

Acknowledgments

We thank Prof Erika Ota at St Lukes International University in Tokyo for translating the paper published in Japanese[ 35 ]. Mercedes Bonnet at the World Health Organization translated the papers published in Portuguese. With thanks also to Maeve Regan and Hannah Tizzard at The University of Central Lancashire for their help with the searching and screening process and to Claire Glenton and Simon Lewin at the Norwegian Institute of Public Health for their advice on using the GRADE CERQual tool.

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• 60. Bowser D, Hill K. Exploring evidence for disrespect and abuse in facility-based childbirth: report of a landscape analysis. Bethesda, Maryland, USA: USAID-TRAction Project, Harvard School of Public Health and University Research Corporation, LLC; 2010.
• 62. World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. 2016; Geneva, Switzerland: World Health Organization.

Motherhood Changes Us All

By Jessica Grose May 5, 2020

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The most memorable moment of becoming a mother often involves a single day. You gave birth, or the child someone else baked inside comes into your life. It’s a before, and an after. But that first day is only the beginning of an identity shift that is ongoing and eternal. The person you are after the first year of motherhood is not the same person you are after year three, year 10 or year 40.

That’s why, in honor of Mother’s Day, we decided to look at the whole messy, glorious, complicated story of identity and motherhood.

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We have short essays about how becoming a mother changed the way we look at ourselves, from our relationships to our own ambitions, as well as failure, body image and more, written by Amber Tamblyn, Casey Wilson, Nikole Hannah-Jones, Angela Garbes, Robin Tunney, Jennifer Weiner and several others. There’s a piece by Jenni Gritters about how motherhood rewires your brain, and another by Pooja Lakshmin, M.D., a perinatal psychiatrist, about how not to lose yourself when you become a parent.

During this coronavirus pandemic, it can be hard to know who we are as people, as the barriers between our public and maternal selves have collapsed in ways we never considered. But if there’s one thing to take away from all of these stories, it’s that your identity as a mother isn’t fixed; it’s likely to change in ways that will surprise and maybe even delight, as you and your children grow.

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Descriptive Narrative Essay: Giving Birth

At the moment when I got pregnant, I could not imagine that I would make a courageous step to give birth to someone, and more so, to give birth to someone naturally without any external interference. Throughout my pregnancy, I was reading a lot of accounts of women who have decided to give birth to their babies naturally. Their experiences immensely inspired me, and I became reassured that delivering without any help and assistance from the medication would be an honor for me as a mother. One shall be aware that giving birth naturally entails the motherly motivation. For me, it was particularly important to be fully in control of my body at the moment when the life of my child will begin. I was so convinced that such motivation would result in the successful process of the birth-giving, and the process went really smooth. However, once I found myself in the hospital, I felt the fear throughout my body. In every part of myself, I was afraid that something might be wrong and I may lose control over the process, and ultimately the delivery will not be safe for my baby.

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Because of the fear, the hospital staff had to interfere in the process of birth giving. The midwives were continually calming me down as I was shivering. Without measuring my blood pressure, I could feel that it went beyond the norm. Instead of thinking of the health of my baby, I was concentrating on the amount of blood, the process of something I wasn’t sure I would be able to control. Even though I thought I was prepared for the process of giving birth, in the hospital room, I realized that it was something a mother-to-be cannot prepare for.

Once the experience of giving birth has started, it has lasted for about 11 hours in total. The midwives were constantly present next to me and were working on stabilizing my emotional experiences. As I was feeling that the baby was actually coming, the fear was fading away. The amount of time spent in the hospital room felt different. After leaving the room, I would not believe that the experience has lasted for 10 hours. I realized that the fear also influenced by the amount of time spent in the hospital room during the process of giving birth to a baby, too.

Lying for 10 hours and giving birth was not as easy as one may think. Once the fear was becoming stronger, I was feeling nausea. During labor, I was trying to portray the images of the baby that was coming from my body but was hearing the cries in my head. The stress and the fear combined was hard to challenge. The only two factors that drove in the process of giving birth naturally was the pride of managing to overcome one of the most massive challenges for the motherhood as well as the motivation for becoming a hero to myself.

In the end, I managed to overcome the fear. After 10 hours of the hardworking labor, my child was put on my breast, and the feeling of pride was omnipresent throughout my body. Finally, in a second I was able to listen to a heartbeat of my body as well as to listen to my body. I was feeling myself a very proud mother who succeeded in overcoming one of the greatest personal challenges one could select. The congratulations coming from the midwives cheered me up even more, and I could finally feel all the pride I had in me. This is why, the experience was wonderful, as it taught me how to overcome my fears.

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A narrative analysis of the birth stories of early‐age mothers

Anna carson.

1 School of Population and Public Health, University of British Columbia, Vancouver, Canada

Cathy Chabot

Devon greyson.

2 Child and Family Research Institute, Vancouver, British Columbia, Canada

Kate Shannon

3 British Columbia Centre for Excellence in HIV/AIDS, Gender and Sexual Health Initiative, Vancouver, British Columbia, Canada

4 University of New South Wales Faculty of Medicine, Kirby Institute, Sydney, Australia

Jean Shoveller

The telling of birth stories (i.e. stories that describe women's experiences of giving birth) is a common and important social practice. Whereas most research on birth narratives reflects the stories of middle‐class, ‘adult’ women, we examine how the birth stories told by early‐age mothers interconnect with broader narratives regarding social stigma and childbearing at ‘too early’ an age. Drawing on narrative theory, we analyse in‐depth interviews with 81 mothers (ages 15–24 years) conducted in Greater Vancouver and Prince George, Canada, in 2014–15. Their accounts of giving birth reveal the central importance of birth narratives in their identity formation as young mothers. Participants’ narratives illuminated the complex interactions among identity formation, social expectations, and negotiations of social and physical spaces as they narrated their experiences of labour and birth. Through the use of narrative inquiry, we examine the ways in which re‐telling the experience of giving birth serves to situate young mothers in relation to their past and future selves. These personal stories are also told in relation to a meta‐narrative regarding social stigma faced by ‘teenage’ mothers, as well as the public's ‘gaze’ on motherhood in general – even within the labour and delivery room.

Introduction

The historical and ongoing prevalence of stories about key life events reveals the centrality of narratives as a source of knowledge about social life. Stories are told (and re‐told) in the form of ongoing and evolving sources of information, knowledge construction, and sense making (Larkin et al . 2009 , Williams 1984 ), although the use of narratives as an organised version of reality and a legitimate form of ‘knowing’ has been problematised in various forms and for reasons of both ontological and epistemological origin (Meretoja 2014 ).

The telling of stories that describe women's experiences of giving birth is a common and important social practice in many cultures. These stories tend to feature descriptions of experiences with pregnancy and preparation for childbirth, the experience of labour, and the birth itself. Birth stories are sometimes told as a culmination of other key events, such as conception or longer‐term postpartum experiences (e.g. children's developmental milestones). And it is through narrated processes that birth stories and their intersections with other narratives help to situate mothers and others within the broader social, cultural, and indeed, medical worlds (Cook and Loomis 2012 , Dillaway and Brubaker 2006 , Larkin et al . 2009 , Malacrida and Boulton 2014 ).

The peer‐reviewed literature includes few birth stories from mothers under the age of 25 (i.e. early‐age mothers), although strong, and often discriminatory, narratives about early motherhood serve to construct these mothers as social deviants (Brand et al . 2014 , Dillaway and Brubaker 2006 , Kelly 1996 ). By giving birth to their children before finishing high school, getting a job, or getting married, young mothers’ life stories (especially those of young, single mothers) stand in stark contrast to authorised chronologies of normative modern Western motherhood (Barcelos 2014 , Breheny and Stephens 2007 ). While much has been written about the power of stereotypes to stigmatise early‐age mothers (Breheny and Stephens 2007 ), only a few studies have been published regarding early‐age mothers’ experiences of giving birth. The existing empirical research suggests that women's experiences with and feelings about childbirth may differ across age groups (Pillitteri 2009 , Low et al . 2003 , Nichols et al . 2014 , Sauls 2010 ). For example, Low et al . ( 2003 ) suggest that early‐age mothers are more likely than older mothers to perceive the responsibility of being a parent as being more ‘painful’ than the physical pain associated with labour and birth (whereas ‘older’ mothers are more likely to express concern about the physical pain of labour and birth). Other research has found that early‐age mothers are less likely to describe being satisfied with their birth experiences than older women (Public Health Agency of Canada 2009 ), although the reasons for this remain unclear. Bissell ( 2000 ), however, suggests that other factors (e.g. ethnicity or social class identities of mothers) may explain differences in birth stories between early‐age mothers and other mothers. In their examination of young mothers’ birth narratives, Nichols et al . ( 2014 ) found associations between birth satisfaction and adolescent mothers’ sense of agency and experiences of positive support. Together, these studies indicate a complex relationship among age, other socio‐demographic factors, environment and personal agency – all of which may contribute to young mothers’ birth experiences. Building on this nascent body of literature, we undertook the current analysis to contribute to enhanced understandings of how early‐age mothers situate themselves and other people, such as their children, spouses/partners, as well as healthcare providers, in their stories about giving birth (Barcelos 2014 , Nichols et al . 2014 , Sisson 2012 ).

We employed narrative analysis techniques (Cortazzi 2001 , Mishler 1986 ) to analyse the birth stories presented to us during in‐depth, individual interviews with 81 mothers (aged 15–24), seeking to understand how their telling of birth stories served to make meaning out of their experiences. Narrative inquiry concentrates on the stories that people tell; it positions those stories as having central roles in identity formation, and in contextualising and explaining the significance of key life events (Clandinin and Connelly 1998 , Mattingly 1998 ), which we suggest is particularly relevant to studying birth stories (Erdmans and Black 2015 ). Narrative has been acknowledged as a means to recount and make sense of past events – and, as being reflective of who the teller was, is, and may become (Cortazzi 2001 ). We recognise that stories told within a research interview context may take on a particular form and content, and that such narratives might differ from stories one might tell peers (Ochs and Capps 2001 ). However, we suggest that all narrative accounts, including those gathered through research interviews, are partial and shift over time, context, and according to audience (Cortazzi 2001 ). Moreover, the potential schism between a teller's actual experience and their representation of that experience is of import within narrative inquiry – indeed, the way one tells a story helps to reveal its meanings (Cortazzi 2001 , Good 1994 ).

This analysis is based on data gathered during an ongoing longitudinal study of the lived experiences of young parents in two metropolitan regions of British Columbia (BC), Canada: Greater Vancouver (GV), pop. 2,313,328 (Statistics Canada 2011) and Prince George (PG), pop. 71,974 (Statistics Canada 2011). BC's largest metropolitan area is GV, while PG is the largest city in northern BC. PG is a regional hub for services designed to meet the needs of early‐age mothers, including education and healthcare services. In Canada, the total fertility rate has decreased: this is attributed primarily to the decreasing number of births to women who are under the age of 30 (Statistics Canada 2013 ). In 2011, more than half of all live births in Canada occurred among women who are over the age of 30 (Statistics Canada 2013 ). BC's age‐specific fertility rates (ASFR) are lower than the Canadian average for all age groups, except among women who are 45 years or older (Statistics Canada 2013 ). The ASFR for mothers under 20 in BC was 7.0/1000, and for women aged 20–24, the rate was 30.2/1000 (BC Statistics 2015 ). In PG, the ASFR for mothers under age 20 was 15.9/1000, and 64.0/1000 for mothers ages 20–24 (BC Statistics 2015 ). Comparatively, across GV, the ASFR for women ages 15–19 was between 0–2.8/1000, and between 3.7–13.9/1000 for women ages 20–24 (BC Statistics 2015 ). In contrast, the national ASFR for women aged 30‐34 was 98.1/1000 (Statistics Canada 2013 ).

In BC, the cost of antenatal and birthing care is typically covered by the provincial health insurance plan, the Medical Services Plan (MSP). Through MSP, a pregnant woman may choose a family physician, an obstetrician, or a licensed midwife to act as the primary caregiver during pregnancy, labour, and during the post‐natal period (Provincial Health Services Authority 2014 ). Guidelines for care of pregnant women in BC vary by professional group; however, all publicly funded services endorse a ‘woman‐centred’ approach (British Columbia Perinatal Health Program 2010 ). This approach is described as relying ‘on understanding women's preferences and needs with respect to care. It also involves engaging women and their families (as defined by the woman) as partners in the processes of planning, delivering and evaluating services’ (British Columbia Perinatal Health Program 2010 ).

An appreciation of the sociocultural and historical impact of colonisation is also important to the current analysis. PG lies within the traditional territories of the Dakelh First Nations People, while GV exists on the traditional territories of the Coast Salish, Musqueam, and Tsleil‐Waututh. Recently, the Truth and Reconciliation Commission of Canada ( 2015 ) released a report documenting the cultural genocide committed against Indigenous 1 peoples of Canada. The report highlights the impacts of the systematic removal of Indigenous children from their families and communities to so‐called ‘residential schools’, with the singular objective of breaking children's links to their Indigenous cultures and identities. The report states ‘[i]n establishing residential schools, the Canadian government essentially declared [Indigenous] people to be unfit parents’ (The Truth and Reconciliation Commission of Canada 2015 : 4). The ramifications of these actions are only beginning to be acknowledged and addressed by Canadian society and are particularly important in helping to contextualise the narratives of mothers in our study who self‐identify as Indigenous. According to the latest available Census, 4.8 per cent of the entire population in BC identify as Indigenous; while less than 2 per cent in GV and over 11 per cent in PG identify as Indigenous (Statistics Canada 2007 ).

Recruitment and data collection

Participants in each city were recruited through three alternative school programmes as well as five community‐based youth and parenting programmes using both passive and active recruitment methods. Recruitment posters were posted at each site. Research staff also visited each site multiple times, explaining the study to all programme participants and inviting them to participate. Some of the programmes also agreed to post recruitment information about our study on Facebook pages accessed exclusively by programme members. Women were eligible to participate in an interview if they were between the ages of 15–24, were pregnant or had a child/children, were fluent in English, and lived in one of the two study communities. Written informed consent was obtained from participants prior to each interview. Interviews were conducted in private spaces and the interviews were open‐ended and conversational in style. Two research staff and one doctoral student conducted the interviews. One of three interviewers was a parent and all were female, white, and in their thirties or early forties. Questions from the semi‐structured interview guide covered a range of topics, including: preparations for labour, experiences during labour and birth, and perceptions about others who figured in their stories about giving birth. Each interview took between 40 minutes and two hours to complete; all interviews were audio‐recorded and transcribed verbatim. All participants were provided with a $30 cash honorarium. Participants were offered the opportunity to review and revise their interview transcripts. This study was approved by the University of British Columbia's Behavioural Research Ethics Board (Certificate #: H13‐00415), as well as by the school boards that operated each alternative education programme for young parents. Two school boards agreed that young parents under the age of majority should be considered emancipated minors and did not require us to obtain parental/guardian consent; a third school board required active consent from parents/guardians on behalf of young mothers who were classified as minors.

Data analysis

We drew on techniques associated with narrative inquiry (Clandinin and Connelly 2000, Mishler 1986 ) to illuminate the meanings that these young mothers ascribe to giving birth and to examine the meanings of the key experiences described within their birth stories. To guide our approach to analysing and interpreting the birth stories as told to us, we employed techniques described by Cortazzi ( 2001 ), examining the elements of each story in an effort to identify the meaning that the events hold for the storytellers. These dimensions commonly included a description of the events (e.g. who, what, when and where); the experiences that the narrator ascribes to those events (e.g. feelings, reactions and meanings); the form of the narrative (e.g. oral or visual); as well as moral and aesthetic evaluations of the events (Cortazzi 2001 ). We also identified other characteristics in the stories such as voice, verb tense, points that are emphasised or downplayed, and aspects that may appear contradictory to one another (Cortazzi 2001 ). We searched across stories for central patterns or themes, which we refer to hereafter as narratives. In our analysis, we treated the mothers’ birth stories as representations of their individual and relational constructions of key events. We recognise that their storytelling and our analysis of their stories involved choices by them and by us – choices about what aspects of stories to tell or omit and which pieces to emphasise or to downplay. The interviews also involved interpretations during the acts of telling and listening (e.g. mothers’ reactions to the interviewer's verbal and non‐verbal cues; mothers’ own somatic and emotive manifestations involved in telling and having their stories listened to) (Bamberg 2012 , Cortazzi 1993 ).

After being stripped of all identifying information, accuracy checked, and member checked (81% of participants opted to review their own transcript), interview transcripts were uploaded into NVivo 10 (QSR International, Brisbane). Transcripts were then read and reread to inform initial conceptual coding efforts. Utilising thematic content analysis, we identified individual‐level concepts in the interviews, and then discussed, revisited, and compared those concepts with data from additional interviews. Six research team members participated in the initial coding and data analysis. Findings were discussed and analyses revised at team meetings. We used this process to begin to identify nascent themes across the interviews. Participants’ transcripts and our accompanying fieldnotes were frequently re‐read throughout the analysis to ensure that we understood the chronology presented within the narratives as well as to help the analysis stay as close as possible to the described experiences and contextual factors that mothers featured in their stories (e.g. social position and intimate or familial relations) (Cortazzi 2001 , Erdmans and Black 2015 ). As new interviews were completed, we continued to use this comparative approach to both identify and test emergent themes.

We interviewed 81 mothers (ages 16–24) across both study sites. Most identified as White and/or Indigenous, were completing their high school education, and had one child. Most participants (n = 51) told stories of their first childbirth experiences, although some told stories that included events from the birth of previous children. Three major themes emerged in our analysis of these young mothers’ birth stories: (a) the role of the birth in participants’ identify formation processes; (b) ‘bearing up’ under pain and desire for ‘natural’ childbirth; and (c) managing the complex social spaces in which these births took place (Table  1 ).

Socio‐demographic characteristics of study sample

Identity formation: capable, competent and mature

Forming an identity as a capable, competent, and mature person emerged as a central theme across the interviews. Constituting oneself as mother and managing the life transitions that accompany that experience were discussed in great detail. Mothers concentrated primarily on establishing themselves as a person ‘fit’ to be a mother. Stories that emphasised previous experience in caring for children featured strongly. For example, one participant explained that she had raised her younger siblings before she herself became a mother, using this aspect of her story to position herself as capable and competent to provide care for her own child:

I was the ‘mom’ in the house and … yeah. I pretty much, like … raised them for a long period of time and … you know, they would always ask me if they were allowed to do things. Like, they would never ask my mom. So they would ask me if they're allowed to go outside or ‘What time's dinner? When are we having dinner?’ (009‐PG, age: 19, Indigenous)

Demonstrating insight into what attributes constitute socially accepted competencies and qualities of good mothers (e.g. prepared; loving; attached to baby; selfless) was also an important feature of these narratives. Representations of maternal instincts were presented as being central to forming an identity as a mother. The interviews also included many examples of mothers ‘learning’ to trust their own instincts, as well as their deliberate acts of ‘learning motherhood’. For example, when asked how she determined what kinds of foods she should eat during her pregnancy, one mother explained:

Definitely from the doctor and my mom. But also just what I felt was right to do, so … that was a big part in what I felt was right. (017‐GV, age: 21, White)

Narratives that included descriptions of deliberate and learned acts of preparation (e.g. attending antenatal classes) revealed the value placed on knowledge about giving birth and parenting that is learned from health professionals. These stories offered an important opportunity for mothers to describe their understanding of the social significance of actively preparing to be a good mother, and appear to have a bolstering effect on establishing oneself as capable, competent, and mature. The mothers told stories about seeking out specific training (e.g. the ‘right’ antenatal class) and expertise (e.g. doula; midwife; nutritionist) in order to help prepare themselves for the birth process and becoming a mother. Some mothers also emphasised their ability to navigate the bureaucratic aspects of preparing for the birth of a child (e.g. applying for maternity leave from her employment). Stories that demonstrate maturity and competency were particularly important to mothers who were under the surveillance of the State (e.g. they reported to social workers). Expressing the ways in which they resist the stigmatising effects of being under State surveillance provides much cherished opportunities to exercise agency and demonstrate competencies as a mother and an adult, as the following quote illustrates:

I knew if you have any like questions about the government [services] kind of thing, [the social worker] was supposed to take care of it. I was gonna ask her about my maternity leave, but I already figured it out … ‘cause I researched it online. (001‐GV, age: 17, Latina)

Bearing up under pain and desires for ‘natural’ childbirth

While previous empirical research (Low et al . 2003 ) suggests that ‘teenage’ mothers may not be greatly concerned with the physical pain of labour and birth, pain was central to the stories told by almost all mothers in the current study. Their stories of pain tended to be told as stories of stoicism or humour, where pain features as a marker of ‘natural’ childbirth and a precursor to the reward of producing a healthy child. As one mother's story emphasised, bearing up under pain while giving birth also was highlighted as a valorised achievement:

[I]t's the hardest thing in the world, going through labour. I tell you, like, there's a lot of scary things but there's nothing like being in labour. (009‐PG, age: 19, Indigenous)

A strong feature of the pain thematic drew upon mothers’ descriptions of an idealised version of how a mother should behave during childbirth, reflecting internalised notions of how women in childbirth ‘ought to’ behave. This included descriptions of stoicism, calmness, and rationality in the face of severe pain or health emergencies (for themselves or the baby). Having one's pain and stoicism witnessed and acknowledged by those present at the birth was highly valued by mothers and served as external confirmation that their efforts to endure or bear up were valorised as a social norm. One mother's narrative describes how her baby remained in occiput posterior (face‐up) position until her final push, and the stoicism with which she had endured that pain:

So I felt bad ‘cause it hurt and then, yeah. My dad said, ‘She only cried one tear … at the end’. I was, like, yeah, ‘cause the last push, it – that one was the one that really hurt. (019‐PG, age: 22, Indigenous)

This mother's narrative utilises her father's voice (as well as her own) to highlight her stoicism, strength, and endurance during her labour. This story, like similar stories of stoicism presented by other participants, was told with a sense of pride, revealing an understanding of the social importance of enduring pain as gracefully and heroically as possible.

Enduring pain and its importance in conforming to ‘natural’ labour and birth also emerged strongly across participants’ birth stories. The desire to measure up to a predetermined ideal of ‘natural’ childbirth emerged as an important marker by which the young mothers in this study self‐evaluated their own performance of childbirth. For many participants, this ideal was characterised as a vaginal birth with minimal medical intervention, two notions that appear frequently within dominant narratives about ‘natural’ childbirth. For example, one mother described feeling proud that her experience conformed to an ideal version of how she understood labour and birth ought to progress, naturally:

[T]here's 10 centimetres of dilation. You're supposed to dilate one centimetre an hour. So that's pretty much what happened. [Laughs] I, like, had the, like, textbook‐perfect birth and I didn't have to, like, get an epidural or anything, which I was happy about ‘cause I didn't want to use very much medication. (029‐GV, age: 19, White)

While her narrative includes descriptions of having been in pain during her labour, the chosen emphasis within the narrative rests instead on the ways in which her labour conformed to an idealised process of giving birth. In this way, markers of ‘natural’ birth (e.g. dilation of 1 cm/hour; minimal use of drugs; vaginal birth) also emerge as markers of the normalcy of their birth stories, which in some cases appear to reflect a desire to align their stories with those told by mothers who do not face ageism, classism, and racism to the same degree faced by most of the mothers in the current study.

Stories about ‘natural’ births also were told so as to emphasise a mother's innate, almost biologically‐determined ability to create a healthy birth experience and, ultimately, to produce a healthy child. In fact, stories that downplayed the pain experienced during labour frequently segued into narratives that focused on the ultimate result – the birth of a healthy child. In all the interviews, the pain of childbirth was characterised as having been ‘worth it’, as an excerpt from this mother's birth story illustrates:

The reality was that I would most definitely love to go through labour again … yeah. I would love to. I was scared, obviously. I knew it was gonna hurt, but I was extremely, extremely excited, uhm, to finally have my son – and the labour was hard. But I barely even remember the pain because … it ends. It happens so quickly … even though it lasted 26 hours. It comes on so quickly and then when it ends, it's done. Like, when it's done it's done and you have your son or your daughter. (021‐GV, age: 20, White)

A number of participants suggested that their young age was, in fact, a benefit in terms of feeling more physically resilient and better able to easily give birth. Birth stories where mothers characterise their experience of giving birth as a natural, easy process, also were frequently recounted with a degree of aplomb:

It was good. It was easy. I ended up all natural. No drugs. Popped that sucker out! (015‐PG, age: 20, White)

Similarly, another mother spoke about how easily and quickly she gave birth to each of her two children, inferring that labour and giving birth is something that she is capable of doing well and with confidence:

With [my older son] I was only … in labour for eight hours and I – he came out within, like, five minutes. And then [my younger son] … I was in labour and he was out of me within two hours. So super fast. [Laughs] … So labour is not a problem for me. I'm not afraid of labour. (023‐GV, age: 22, White)

There also is a bravado inherent in the telling of this story that demarcates her birth experience as an achievement that speaks not only to her value as a mother, but also to her standing as a person who can accomplish something important with minimal trouble. Given the degree to which many of the mothers in the current study have experienced marginalisation, stories told with such confidence and with respect to personal competence register a challenge to prevailing and stigmatising narratives regarding early‐age mothers.

These kinds of ‘natural’ birth stories stand in stark contrast with those where an experience of giving birth was described as ‘unnatural’ (e.g. a C‐section was performed). Those stories, instead, were used to convey a sense of not having ‘done’ birth the proper way. In one mother's story, she used the word ‘easy’ to describe her emergency C‐section, following 26 hours of labour:

It wasn't as bad as I thought it would be. What I think would have been the worst part was when I had to push. But I didn't. I think I got it the easy way, having the emergency C‐section. (028‐GV, age: 17, Indigenous)

Within this mother's description, the pain she felt during 26 hours of labour (longer than many other participants’ entire labour and birth experiences) was downplayed in comparison to the anticipated ‘natural’ vaginal childbirth. This quote illustrates the broadly held sentiment expressed by almost all mothers in the study (regardless of their ethnic identity or city of residence) – having a C‐section is widely perceived as a failure because it is perceived as a most ‘unnatural’ form of childbirth.

Situating oneself as the protagonist in a story about naturally and easily birthing a healthy child also offers important social and personal currency. These stories are told to friends and family; and in some cases, also are told to people in positions of authority (e.g. social workers; nurses) – including those with the legal powers to remove children from the custody of their mothers. In fact, being able to describe oneself as a ‘natural’ mother (e.g. through stories that feature the natural, easy birth of a perfectly healthy child) was sometimes presented as a form of evidence to counteract concerns about a mother's competence. One mother, for instance, had lived in foster care for part of her childhood and said her family had a bad ‘reputation’ with social services. She was very concerned that her baby might be apprehended at birth, a fear more commonly voiced by the Indigenous mothers in the study. She chose not to take any painkillers during her labour, in part, because she was afraid that it might demonstrate to child protection workers that she was not a suitable mother:

Like for the birthing … they were asking me what [drugs] I wanted to take … And, I just wasn't too sure, ‘cause you never know with medication. And actually I had a friend that took something for the birth and it showed [in a subsequent drug test] that she did drugs, when she's not that kind of person. And, they instantly took that baby … So, I didn't take anything [during labour]. It was pretty crazy. I was scared. (004‐PG, age: 19, Indigenous)

Stories where apprehension concerns feature strongly, particularly among Indigenous participants, tended to position the mother and her family history as a co‐produced protagonist facing unreasonable thresholds in terms of the production of a healthy child, revealing the combined impacts of ageism, racialisation, and overall high child apprehension rates. Birth stories about the production of a healthy child also included details about the mothers’ exemplary antenatal behaviour (e.g. many took antenatal vitamins; quit smoking; avoided certain foods; and/or completed antenatal education classes).

In general, there is a form of competency demonstrated in the telling of a ‘natural’ childbirth story – and, these stories were frequently told as representations of a performance of strength and grace, culminating in achievement, as this mother described:

And I was, like, this went by, like, so fast, these, like, however many months […] It flew by and, like, she came out so perfectly and she was healthy. And there's ‘absolutely nothing wrong with her!’ So I was really proud that I was so young, but I did what I could. (017‐PG, age: 20, Indigenous)

Recounting natural birthing experiences helps to underscore the teller's readiness to be a skillful mother – a powerful bolster to one's efforts to formulate a socially‐acceptable maternal identity in the face of broader stigma that pathologises early‐age motherhood and their children.

Humour was frequently used as a rhetorical device to describe dramatic or traumatic moments within these birth stories, and provided a socially acceptable means of telling others about the pain of labour and giving birth. The use of humour allowed mothers to position themselves as both the teller of the joke and the subject of the joke; and, in this way, humour provided a means to re‐claim their centrality and control in their birth narrative. For example, one mother used humour to reframe her experience of having had severe tearing of her perineum as well as voiding her bowels during labour as a ‘positive’ in the overall experience of giving birth. Her use of humour was used to at once recount and discount an extremely painful experience (multiple tears to her perineum):

I ripped; yeah, I got a second‐degree tear. I ripped to the side and I ripped up – I actually crapped the whole time I gave birth … And, you know, most women … always are, like, ‘Oh, my god! I don't want to crap!’ … ‘Oh, my god, it's the worst thing ever’. And, I'm, like, holy shit, you ‘definitely’ want to crap [during labour] because I had stitches and I didn't have to poo for the next three days ‘cause I was completely empty. [Laughs] And it was a blessing. (015‐PG, age: 20, White)

Being able to provide an ‘entertaining’ narration to their experience was also used to describe the mother's centrality to the birth experience and as a means by which we learn about the mother's interactions with other people who attended the birth (e.g. doctors; family members). In this way, the birth narratives presented by mothers in this study reflect experiences that included the interviewer, as well as providing a means by which we heard about the reactions of other, broader audiences, as the following example illustrates:

It wasn't my [regular] doctor, but it was this British doctor and … at the end of my birth, um … he comes in, shakes my hand and he's, like, ‘You were one of the funniest clients and women I've ever experienced going into labour and having a child’. He's, like, ‘Next time you have a kid make sure you come back to me’. (017‐PG, age: 20, Indigenous)

This story was told with a sense of pride, positioning the young Indigenous mother as the central, powerful and positive character in her narrative, and sets up a future story where a medical professional is waiting to receive her.

The labour and delivery room – a complex social space

Participants’ stories of giving birth were told in relation to the seemingly ubiquitous public ‘gaze’ on motherhood in general. Becoming a mother has been described as an act that puts one in the public gaze (Good 1994 ) – even during intimate moments such as labour and delivery, where mothers are the central characters and manage the complex social relations that arise amongst the various actors in this setting. Participants in the current study also told their stories in relation to widespread social stigma faced by early‐age mothers within the Canadian context. These two broader phenomena were reflected in key aspects of the mothers’ stories about the labour and delivery room – who gets to be in the room, what they do, and how those actions are (re)constructed by mothers as they re‐tell the experience.

For some participants, stories about those people who were present in the labour and delivery room reflected the culmination of a long planning process (e.g. invitations to attend the birth had been issued well in advance of the due date). Other mothers described the spontaneous, sometimes unwanted, presence of other people at the birth. For example, one study participant described how her partner's mother tried to ‘scare’ her own adolescent daughter by forcing her to watch the birth at close proximity:

His mum made his little sister watch the entire thing. I think she was like trying to scare her into not getting pregnant. … Uh, she was, like, 13 or something, but she made her stand at, like, the foot of the bed. (010‐PG, age: 20, Indigenous)

In recounting this story, this mother was upset by the notion that a young girl was forced to watch a birth as a means to frighten her into chastity, but she went on to explain her reaction at the time she was giving birth:

I was more in just so much pain, I just didn't care who was there or anything. I just didn't care. (010‐PG, age: 20, Indigenous)

Many other mothers, however, positioned their actions as assertively managing or even determining, who else was inside (or outside) the labour and delivery room. One mother, for example, recounted with a sense of pride and achievement how she had been the person who ultimately decided which family members would be present in the delivery room. When her boyfriend's grandmother (who had raised her boyfriend) showed up uninvited, she asked her boyfriend's grandmother to wait outside:

Well … [my boyfriend's grandmother] wanted to be there when [our son] was born, like, in the room. And I wasn't quite comfortable with that because … I didn't really know her all that well. And I'm, like, ‘I don't think I want you in there. I mean, I know it's your family, but, like, I'm not comfortable with that’. I mean, it's my body. … She just showed up at the hospital and she came into the room while I was having him. And I'm, like, ‘Um, no! Like, no, I don't want you in here, sorry’. So then my boyfriend told her, like, ‘Can you just wait out in the hallway? We'll call you as soon as he's born’. … So then she was quite pissed off. She, like, walks out and is, like, ‘Well, fine then’. Slams the door and I'm, like, really? Like, you're just making this worse. (024‐PG, age: 18, Indigenous)

Some narratives that we initially coded as powerful, managerial‐like birth experiences, were revealed as we re‐read the transcripts to concomitantly reflect vulnerability and strength, as the following excerpt from this mother's story illustrates:

And then I kicked everybody out of my delivery room. I just did it by myself because I just – I don't know, I'm kind of a do‐it‐myself person. Never really – I don't really trust – well, it's not that I don't trust, it's just that I don't like having help. Like, I'm quite capable of doing it on my own. (017‐PG, age: 20, Indigenous)

This participant later revealed that she had been victimised by family members during her childhood and had kept this fact hidden in order to prevent herself and her siblings from being placed in foster care. Years later, at the time of giving birth to her own child, she was simultaneously struggling to establish clear boundaries with her family while acknowledging that strong familial connections are integral to her identity as a good mother. This is an example of a story that carries within it other stories – a frequent occurrence, as not surprisingly, the narratives told to us during our interviews also needed to accommodate previous narratives (e.g. the value of secret keeping) that have been established previously in a mother's life.

The sub‐narrative about managing the room also is a story of things that cannot be managed – even by the most capable mother. For example, there were numerous stories that described the disappointment and frustration of not having a birth attended by the healthcare provider with whom participants had established a relationship with throughout their pregnancy (e.g. their family doctor). These stories frequently featured distressing examples of mothers in the midst of labour and delivery needing to explain important aspects of birth plans to healthcare providers who were unaware of those particulars. In some instances, mothers described how they resorted to confrontational tactics in order to re‐assert their original birth plan, as one mother's story illustrates:

[The nurse] kept asking me, ‘Now do you want an epidural? Do you want an epidural now? Do you want an epidural now?’ I was, like, ‘I want a natural birth. Stop asking me. I don't want to have drugs … That's manipulating my body, you know? … The final straw for me was [my partner] was, like, ‘You heard her. She said she doesn't want it and you're asking her right in the middle of a contraction. We have talked about this for months. She does not want it’. And she [the nurse] was, like, ‘You have no idea what she's going through,’ … ‘you have no right to tell her what she can and cannot do’. And it's, like, ‘ You have no right [to speak to him that way]. He is my partner. We have done birthing classes together. We have talked about this for hours. We have written it down. We have talked to our midwife. We have done everything! And you … you have no right to tell me what I want’. (008‐PG, age: 18, White)

On occasion, mothers described the perception that their centrality to labour and within the delivery room was being disregarded altogether, or described a feeling that they had been pushed to the fringes of the birthing experience. One mother spoke about how a physician decided on an operative vaginal delivery without consulting her:

The staff there don't treat you like a human being. It doesn't matter if you're 15, you're still, you know, you should still be treated equally. They just did forceps on [my baby] without even discussing with me. There was so much going on that I didn't even realise how bad they were treating me. (006‐GV, age: 20, White/Chinese)

This experience remained as a very painful and emotionally wrought memory for this mother four years later when she described it to us.

While these stories denote distinctly negative descriptions of the interpersonal experience with a ‘professional authority’ (e.g. a nurse or doctor), other young mothers’ stories described how having a ‘professional authority’ in the room was helpful. Professionals who ‘stood by’ the young mothers (e.g. doulas who reinforced their perception that it was their right to be treated well within and beyond the labour and delivery room) were characterised as bolstering forces within the mothers’ stories. Those professional authorities that contributed (deliberately or inadvertently) to the mothers’ sense of resilience during labour and delivery were also frequently credited with helping to build mothers’ confidence in their own capabilities – during labour and delivery, and beyond.

This paper presents an opportunity to examine young mothers’ stories of labour and delivery – perspectives and experiences that to‐date, have remained under‐examined in the literature. Using narrative inquiry, we were able to examine the ways in which re‐telling the experience of giving birth serves to situate young mothers, both in relation to their past and future selves, as well as in relation to broader social and cultural forces. Participants illuminated the complex interactions among identity formation, social expectations, and negotiations of social and physical spaces as they narrated their experiences of labour and birth. For many participants, their story of being a mother began long before they gave birth to their own children, as many had acted as a caregiver for younger siblings. Participants’ birth stories provide many illustrations of the notions of capability, competence, and maturity. The use of rationality, stoicism, and humour also emerged as important aspects of their birth stories. Many of the descriptions appear to reflect and employ internalised notions of how women in childbirth ‘ought to’ behave (e.g. idealised versions of stoicism; use of humour) and how birth itself ‘ought to’ be experienced (e.g. a vaginal birth with minimal medical intervention). The interviews contained many examples that were at once instantiated as expressions of resistance to dominant narratives about young mothers (e.g. resistance to stigmatising narratives that characterise young mothers as incapable), while also reflecting internalised notions of broader, valorising narratives related to childbirth. In interpreting these stories, it is important to understand that cultural narrative plays an important role in shaping the individual narrative. That the mothers’ constructions of counter‐narratives of resistance also include aspects of existing cultural narratives (e.g. those that valorise natural childbirth) reveals the interplay between cultural and individual narrative.

Further to this point, it is also important to recognise historical and proximate influences on the stories told by many of the Indigenous mothers in the study. For example, many Indigenous mothers had parents or grandparents who as children had been forcibly detained in residential schools. As well, many of the mothers in the current study had personal experiences with social workers and the foster care system. Recent data confirms that over 50 per cent of youth in foster care in BC are Indigenous (Turpel‐Lafond and Kendall 2015 ). These realities affect both the content (e.g. what was included or excluded from the telling) and the rhetorical techniques used in telling their birth stories (e.g. utilising stoicism, humour). Research indicates that there are disparities in the obstetric care received by first time mothers who identify as Indigenous (as compared to non‐Indigenous) in BC, including both fewer antenatal checkups and decreased use of obstetric interventions (Riddell et al . 2015 ). Combined with increased rates of stillbirth and perinatal mortality among Indigenous populations in BC (Luo et al . 2004 ) and across Canada (Smylie et al . 2010 ), further qualitative inquiry utilising a lens of decolonisation and self‐determination has been called for in order to better understand the reasons behind these disparities in obstetric care and outcomes.

While incorporating narratives of the past self, birth stories also contribute to future selves, which simultaneously serve to break down and rebuild the self. In this way, by narrating their birth stories, participants provide glimpses into the complexities associated with becoming a mother while navigating overlapping stigmas and, concomitantly asserting their own version of motherhood. The early‐age mothers in the current study ‘frame up’ their stories against widespread, stigmatised depictions of ‘teen moms’ (as distinct from, and somehow ‘less than’ their older counterparts). Stories with a central meaning of constituting self as mother continue to be told as a form of resistance or at least told in juxtaposition to broader, punishing social stigma and material circumstances. Drawing on Nichols et al .'s ( 2014 ) findings, we suggest that the narratives in our current study reflect mothers’ desires to demonstrate that they are performing birth and motherhood according to normative expectations.

The birth stories gathered through the current study also highlight the ways in which other people impose moralising judgments on young mothers (based on ageism, racism, or classism), even during one of life's most significant moments. Early‐age mothers in Canada report lower satisfaction with their birthing experiences than older‐age mothers (Provincial Health Services Authority 2009). Previous research suggests that clinicians ought to partake in specialised education in order to better meet the needs of early‐age mothers in the delivery room (Low et al . 2003 , Nichols et al . 2014 ). While there are numerous programmes that have been developed specifically to assist young mothers during the antenatal and post‐natal periods (e.g. antenatal classes, post‐natal support groups), we found few examples of research on effective specialised training for healthcare providers who assist early‐age mothers as they labour and give birth. However, the Society of Obstetricians and Gynecologists of Canada's recent publication of adolescent‐specific pregnancy guidelines (Fleming et al . 2015 ) for clinicians is an encouraging development. As healthcare planners consider techniques for improving clinical practice, our findings point towards the need for fully realising interventions that are designed to take a woman‐centred approach to birthing (regardless of maternal age) and that address social phenomena across contexts (e.g. racism; ageism) (Shoveller et al . 2015 ).

Strengths and limitations

Our study methods included purposive sampling and our results are not meant to be representative of all young mothers. However, the rich narratives shared here provide vital insights into the perspectives of a relatively large and heterogeneous group of young mothers from two cities in BC, Canada, including young women who are racialised and further marginalised by socioeconomic factors. Because stories are concomitantly shaped both by storytellers and listeners, we acknowledge that our data are a product of this process. For example, some participants might have emphasised details they assumed that the interviewers wanted to hear and left out other details they were concerned might give us a negative impression (e.g. fear of pain). Moreover, as relative ‘unknowns’ in the interviewee's lives, telling their stories to us (i.e. researchers) might reflect a distinct experience from the birth stories that they may tell others, such as their friends or family members. Finally, although an important focus for our future empirical work, our analysis does not include young fathers’ narratives.

The telling of birth narratives by early‐age mothers provides a means to constitute the self and others within the complex social, cultural, and medical worlds. The stories told here emphasise the various ways that young mothers are competent, capable, and informed. Documenting these stories offers a way to break open a more dominant and negative narrative about early‐age mothers in favour of their own presentations of themselves as characters whose intentions and behaviour run counter to pervasive stereotypes and stigmatised representations. In the absence of these stories, opportunities may be missed that would help us to understand and appreciate the strength and vulnerability of early‐age mothers in the face of society's broader narrative representations of them.

Acknowledgements

We would like to acknowledge the study participants who shared their birth stories with us, as well as the research trainees and staff members who have provided assistance with this study. Funding for this study was provided by the Canadian Institutes of Health Research (MOP‐126032 and GIR‐127079).

1 The term ‘Indigenous’ refers to the First Nations, Inuit and Métis peoples of Canada.

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