See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/44682317

A Mirage of Change: Family‐Centered Maternity Care in Practice

Article  in  Birth · June 2010

DOI: 10.1111/j.1523-536X.2010.00396.x · Source: PubMed

CITATIONS READS

25 2,286

4 authors, including:

Michael C Klein
University of British Columbia - Vancouver
193 PUBLICATIONS   3,809 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Canadian Birth Place Study View project

All content following this page was uploaded by Michael C Klein on 13 October 2017.

The user has requested enhancement of the downloaded file.

160 BIRTH 37:2 June 2010

A Mirage of Change: Family-Centered

Maternity Care in Practice
Vania Jimenez, MDCM, CCFPC, FCFPC, Michael C. Klein, MD, CCFP, FAAP,
Myriam Hivon, PhD, and Catherine Mason, RM, MHSc

ABSTRACT: Background: Since the 1970s, the movement to ‘‘humanize’’ birth in North
America has evolved into ‘‘family-centered maternity care,’’ which has focused on providing
evidence-based maternity care that is responsive to the needs of women and their families.
The objective of this research was to explore women’s birth experiences within the context
of the numerous changes that have occurred in perinatal care and to determine how
information and knowledge acquired about pregnancy and birth influenced women’s birth
experiences. Methods: Semi-structured interviews were conducted in prenatal health clinics
in Montreal and Vancouver with 36 women before and after birth. Results: Most study
participants were unaware of the range of available providers and birth settings. Of the women
who were more aware of their options, those selecting a birth center or home birth and
midwives had different notions of risk than those who planned a hospital birth. Study
participants felt generally well informed, but thought that information sharing, collaborative
decision making, or both were inadequate during labor and birth within the hospital
setting. Conclusions: Despite positive changes in recent years, family-centered maternity care
in Canada still needs to be improved. Women’s ability to use their acquired prenatal knowledge
to feel satisfied by their birth experience continues to be undermined by a system of care that
does not prioritize women’s informed choice. Further systemic change is required to align
maternity care with the needs of Canadian birthing women and their families. (BIRTH 37:2
June 2010)

Key words: birth experience, informed choice, maternity care, prenatal information, qualita-
tive research

Giving birth has strong sociocultural meaning. It is a
woman’s rite of passage into motherhood (1). Complex
psychological and social outcomes result from giving
birth (2,3), and a woman’s satisfaction with her child-
birth experience may have immediate and long-term
effects on her health and her relationship with her infant
(4,5). The experience can affect her response to the
physical and emotional challenges of motherhood, her
sense of accomplishment and self-esteem, her relation-
ship with her partner, and how both she and her partner
individually bond with their baby to form a family
(2–5). A traumatic or unsatisfactory birth can lead to
postpartum depression or post-traumatic stress disorder,
in which women relive their labor in dreams and flash-
backs that trigger extreme distress (4).
Numerous changes have occurred in perinatal care in
Canada in the past 30 years. Policy-makers and health
care practitioners have taken concrete measures to

Vania Jimenez is Associate Professor in the Department of Family Address correspondence to Vania Jimenez, MDCM, FCFPC, CSSS
Medicine, McGill University, Montreal, Quebec; Michael C. Klein is de la Montagne, 5700 Côte-des-Neiges, Montreal, QC H3T 2A8,
Emeritus Professor of Family Practice and Pediatrics, University Brit- Canada.
ish Columbia & BC Children’s &Women’s Health Center, Vancouver,
British Columbia; Myriam Hivon is a Research Professional at le GRIS
(Groupe de recherche interdisciplinaire en santé), Université de Mont- Accepted September 18, 2009
re´al, Montreal, Quebec; and Catherine Mason is a Registered Midwife,
affiliated to La Maison Bleue, Montreal, Quebec, Canada.

The research was funded (Grant #201223) in 2001 by the Social  2010, Copyright the Authors
Sciences and Humanities Research Council, Ottawa, Ontario, Canada. Journal compilation  2010, Wiley Periodicals, Inc.
BIRTH 37:2 June 2010
respond to calls for change from many women who have
fought for a less medicalized approach to birthing, one
that is based on more than just the most efficient and
safe removal of a baby from the mother (6). The family-
centered maternity care movement emerged from the
efforts of women and their supporters who advocated for
an approach to birth that focused on the needs of women
and their families (7–10). Health Canada first published
its Family-Centred Maternity and Newborn Care:
National Guidelines in 1968 and has been revising it
ever since (9,10).
Family-centered maternity care has taken on various
forms within different health care institutions. Because
health care falls under provincial jurisdiction in Canada,
the recent integration of midwifery varies among prov-
inces. At the time of our research, Quebec midwives
operated exclusively in birthing centers; home births
were not yet part of regulated midwifery. In British
Columbia registered midwives attended women either at
home or in the hospital, according to women’s needs
and choices.
Our research questions evolved from the premise that
information sharing and collaboration among child-
bearing women, their families, and staff were the
cornerstones of family-centered maternity care (8).
Prenatal or childbirth education was promoted as a means
to empower childbearing families by helping them to
prepare for active participation throughout the evolving
process of pregnancy, childbirth, and parenting. Included
in the philosophy of family-centered maternity care was
the principle that health care practitioners assist the
family in making informed choices about their care (8).
The study objective was to explore some women’s
birth experiences within the context of the numerous
changes that have occurred in perinatal care since the
evolution of this movement, and to determine how
information and knowledge acquired about pregnancy
and birth influenced women’s birth experiences. We
originally approached this study with two study ques-
tions: First, what kind of knowledge do women have
concerning pregnancy and birthing ⁄ delivery? Second, in
what ways does the knowledge acquired from various
information sources influence women’s experience of
childbirth? As the study developed, we explored the
question of informed consent or choice and to what
extent the proliferation of information actually facili-
tates or interferes with women’s ability to make
informed decisions.
Methods
We recruited a convenience sample of women at prena-
tal classes offered in five community health clinics and
one birthing center from January to June 2002 in Mon-
161
treal, Quebec, and in prenatal classes offered by a family
physician practice maternity group and two obstetrician
offices from February 2003 to April 2004 in Vancouver,
British Columbia, Canada. Based on our own experience
and the findings from Reime et al’s research, we consid-
ered that women cared for by obstetricians, family phy-
sicians, or midwives may hold different values and have
access to different birth discourses (11). Consequently,
we sought to represent care given to study participants
by diverse health care practitioners. Inclusion criteria
included being primiparous and culturally well estab-
lished in Canada (of French or English Canadian des-
cent, and if born outside Canada not being a recent
immigrant). Otherwise, our selection criteria remained
open. The study received ethical approval from the Eth-
ics Committee at McGill University’s Faculty of Medi-
cine in Montreal, Quebec.
Women in both sites were given a pamphlet explain-
ing the study objectives. We contacted the interested
candidates directly by telephone to provide additional
information, establish that participation was voluntary,
and invite them to their first interview.
Data Collection
This qualitative study used in-depth semi-structured
interviews that allowed participants to express them-
selves freely, without imposing the researchers’ precon-
ceptions (12,13). Before the first interview, women
completed informed consent forms. We interviewed 26
women in Montreal and 10 in Vancouver at two time
points—4–6 weeks before their due date and 6–8 weeks
after the birth. Most interviews took place at partici-
pants’ homes.
In the first interview women were asked about their
perspective on the context and experience of their preg-
nancy; their values and expectations about the coming
birth; their knowledge and understanding of the informa-
tion provided in prenatal classes and other sources of
information; the quality of communication they experi-
enced with their health care practitioners; and their per-
ception of their family’s and friends’ values. The second
interview focused on the birth itself, as experienced by
participants. They were encouraged to tell the story of
their birth and discuss gaps between their expectations
and their actual experience.
One interviewer in Montreal and one in Vancouver
conducted the interviews. After the interviews were
transcribed in Montreal, the information was validated
by the participants and the Vancouver researcher.
Names were changed to preserve anonymity. The inter-
views were coded in Montreal by two researchers using
the ATLAS.TI software (14). Several interviews were
double coded to ensure inter-rater coding reliability.
162 BIRTH 37:2 June 2010

Data Analysis learn about birthing during their pregnancy, it is not

Borrowing from grounded theory (12), we developed
analytical interpretations of our material throughout the
data collection process. After coding data from the first
five interviews, we discussed emergent themes and
issues, adding new questions for exploration in the fol-
lowing interviews. In this way, analysis and data collec-
tion evolved in an iterative fashion throughout our
fieldwork. Rather than focusing on comparing the
women’s perceptions of the care that they received
according to care provider and location, we sought to
elucidate the differences and similarities in the emergent
themes of the women’s birth discourses.
Results
Our recruitment strategy had the unanticipated effect of
soliciting a highly educated sample of women, but was
otherwise diverse with respect to age and type of health
care practitioner (Table 1). However, we included in our
study three multiparas and three women who were
recent immigrants.
clear whether the information that they had access to
was accurate, evidence-based, and ⁄ or involved discus-
sion about their role in the birthing process. Before and
throughout pregnancy, these women were exposed to
many different influences outside the medical and ⁄ or
midwifery context. The main sources of information for
the women in our study were brochures, books, and arti-
cles on pregnancy and delivery. They all had read some-
thing about pregnancy and birth.
The second most frequent source of information men-
tioned was health care practitioners, who, in principle,
impart evidence-based information. However, as we
observed in earlier research, variations exist in the provi-
sion of information among health care practitioners
themselves, both individually within disciplines, and
between disciplines (11). Several women characterized
the difference between doctors and midwives by the
doctors’ lack of time to answer their questions.
Doctors are always willing to answer. Of course, when it is a
vague worry, they don’t have the time … They don’t have the
time to show real empathy … But if you have precise anxieties,
focused stress about focused interrogations, they are quite open
to answer. They take the time to answer (FTF, Ingrid, patient of
an obstetrician).

What Kind of Knowledge do Women Acquire About

The encounters before, with our midwives, during the preg-
Birthing ⁄ Delivery? nancy, it’s one hour if we need it . … We have the right to ask
questions; we are not restricted by time. We talk about what we
Sources of information want, so we talked more (FTF, Renée, patient of a midwife).

In the quotations included here, ‘‘FTF’’ in the identifica- The participants’ social networks were also an impor-
tion code means ‘‘free translation from French.’’ tant source of information. Women acquired knowledge
Although the women in this study had the opportunity to based on the sharing of concrete, everyday personal

Table 1. Characteristics of Participants

Characteristics Montreal Site Vancouver Site

Parity 23 primiparas 10 primiparas
3 multiparas
Age (mean) 30 yr 32 yr
Education 18 university 8 university
5 college or professional diploma 2 high school
2 high school
Origin 21 women born in Canada 7 women born in Canada
5 women born outside Canada, 3 women born outside Canada
but only 3 recent immigrants (<3 yr)
Prenatal caregiver 13 obstetricians 3 obstetricians
3 family physicians 5 family physicians
10 midwives 2 midwives
Type of delivery 19 vaginal deliveries 5 vaginal deliveries
7 cesarean deliveries 5 cesarean deliveries
Place of birth 21 in a hospital (including 9 in a hospital (including
5 transfers from a birth center) 1 transfer from home)
5 in a birth center 1 at home
BIRTH 37:2 June 2010
experiences, rather than through scientific evidence.
This information sharing allowed women to individual-
ize the general information contained in the brochures to
focus their choices.
What is interesting about the stories of people who have had
children is that it makes you take with a grain of salt every-
thing you read. Because … you read things that are very
rigid. That’s it! … So, you read theoretical stuff that gives
you a guideline, but the stories of people teach you that it’s
up to you to see and also you must trust yourself and respect
what you believe and value … (FTF, Nadine, patient of an
obstetrician).
It is clear that, evidence-based or not, women sought
out ‘‘expertise’’ that confirmed their intuitions, instincts,
preexisting knowledge, and their own personal values.
And again I was told another story about how to breastfeed and
what the best way of doing it is, and so I just listened and
smiled and said OK, thank you very much, and I just kept doing
what my doula said, because that made the most sense to me
(Jennifer, patient of a midwife).
All the discourses illustrated that the women we inter-
viewed wanted, first and foremost to be reassured. When
she was asked about what she was looking for in her
readings, this woman answered:
Just kind of in general … I guess just reassuring me that what
I was going through was normal … more than anything
(Jasmine, patient of a family physician).
In What Ways Does the Knowledge Gained from Diverse
Sources Inform, or Enlighten, the Birthing Experience?
Our results give us a better understanding of what influ-
ences women’s use of information before, during, and
after birth.
Before labor
Lack of information about choices of birthing loca-
tions. Although it may be generally accepted that most
women choose to give birth in a hospital setting, we
found that little information about how to enter into the
health care system, was provided to women who were
pregnant for the first time. Most women tended to turn
to their social network or their family doctor to find a
birthing location or a health care practitioner who would
ensure proper care.
At the beginning, you wonder what to do, because it is not my
family doctor who will do the follow-up. I asked around me
and then they said: ‘‘You call the hospital.’’ So that is what I
did. I called hospital X because it is the closest one to my place
(FTF, Brigitte, patient of an obstetrician).
163
The notion of safety and risk. An important factor that
influenced the women’s choice of birthing location was
their perception of safety and risk. We noticed a marked
difference in the perception of birthing locations
between women who chose a hospital setting and those
who chose either a birthing center or their home. Indeed,
the notion of safety was a key factor in the choice made
by women who opted for the hospital setting. Despite its
‘‘reputation’’ of being rigid and controlling, for many
women, the hospital remained the ultimate safe place to
bring a child into the world, and this perception took
precedence over all others.
The birthing center, I knew it existed, but I didn’t really know.
But for a first baby I felt safer at the hospital, because they have
all the technology, and if there are problems … I am already at
the right place. So, the fear of the unknown, I’d rather be in a
place where I know that everything is readily available (FTF,
Alice, patient of an obstetrician).
I have heard, of course, of the possibility of giving birth in a
birthing center, but I thought it was not appropriate for me,
because I think that it suits women who are calm and confident
better. Me, I have more of an anxious nature. As I reflected dur-
ing the course of my pregnancy, I came to the conclusion … I
am too able to imagine all the problems that could occur. It
makes me feel safe to be in a hospital (FTF, Jacinth, patient of
an obstetrician).
Meanwhile, women who chose to give birth with a
midwife in a birthing center felt sufficiently reassured
by the close link that exists between the birthing center
and the backup or supporting hospital in case of compli-
cations.
For me, pregnancy is a totally natural thing. If one is in good
shape, in good health, there is no reason why one should go to
the hospital to have access to medical help. Yes, things can go
wrong, and this is why it reassured me to know that midwives
are paired up with the hospital … But if things go well, I have
no reason to ask for a doctor’s help. None (FTF, Judith, patient
of a midwife).
This link between hospitals and birthing centers, in
addition to the professionalism displayed by their mid-
wife, and the bond of trust that was established between
them, was enough for the women to feel confident in the
quality of care. Unlike those followed in hospitals, mid-
wifery clients chose to invest in a ‘‘relationship’’ rather
than an institution.
As a result I don’t feel in non-expert hands or in unknown
ground. I know that the midwives are competent, I know that
they have a training that is super solid, as much as the nurses,
in the sense that it is specialized around birth, so I feel secure
(FTF, Solange, patient of a midwife).
Willingness to participate in decision making.
Contrary to other research findings (15–20), it appears
164
that making one’s own decisions or choices during preg-
nancy and labor was not a priority or preoccupation for
many women in our study. Those who did tell us that
they were informing themselves to make decisions when
required were attended by a midwife or had a doula
involved in their care. The role of information as a tool
for decision making was expressed much more explicitly
by women attended by midwives, such as these three
women:
I want to have things explained. I want to be part of this; I want
to be able to make decisions or [be] a part of them (FTF, Renée,
patient of midwife).
Choice is very important to me. You can really make a choice
when you know all your options (FTF, Valerie, patient of a
midwife).
It helped to think about those things ahead of time so that deci-
sions were really easy at the time [of delivery] (Janet, patient
of a midwife).
During labor and delivery
Feeling informed and the lack of information for deci-
sion making. Although the women in our study felt
well informed, our findings suggest that when labor and
birth actually arrived, application of their knowledge for
decision making was limited. Most women understood
the labor process in theory and were aware of their
options, but several expressed the concern that they
lacked explanations of what was happening to them, and
what was being done to them in the moment. Few
women in our sample thought that they were provided
with space for discussing the necessity of induction, and
women experiencing labor pain were generally not
encouraged to try other means of pain relief before epi-
dural analgesia.
Only 5 of the 11 women attended by obstetricians
were offered an alternative to epidural analgesia for pain
management. Three women initially tried nitrous oxide
which did not really help, so they wound up asking for
an epidural. A fourth woman was given an epidural after
being told that narcotics would only last an hour or so,
thereby giving her the impression that they were proba-
bly not worthwhile.
Kate’s situation is different. She was aware of her
options and she asked for what she wanted. Her experi-
ence showed that even though many options are avail-
able, they are not systematically offered to women in
labor.
My husband said … we’ve read a lot about this walking epidu-
ral, but we understand that not many people are given the walk-
ing epidural. She [the anaesthesiologist] said: ‘‘I can do that.’’
And the doula was shocked. She said in 16 years of attending
BIRTH 37:2 June 2010
births, she’d only ever seen two walking epidurals being admin-
istered. … She gave me the walking epidural, and the nurse as I
remember was actually really surprised as well. ... It was just
great and I just was relaxed a bit, and I was able to walk to the
bathroom and go to the bathroom, and I really don’t know why
they don’t do the walking epidural more often (Kate, patient of
an obstetrician).
Women do not always seem to be in a position to ask
questions. The women in our sample who had continu-
ous experienced labor support were those who benefited
most from being informed when entering into labor, and
in turn, were offered more choices and were better able
to avoid certain interventions.
Feelings of nonparticipation in decision making.
Whether they had expressed a desire to take part in
decision making or not, the fact remains that some study
participants felt they were excluded from the decision-
making process during labor.
These feelings existed among several respondents
who chose to give birth in the hospital setting, and even
more profoundly among the five women who were trans-
ferred from the birthing center to hospital.
Then the midwife says to me, ‘‘Ah! The nurse is starting the
Pitocin.’’ So I turn and I say to the nurse, ‘‘No! I thought we
would discuss this again.’’ The resident had said that he would
come back and discuss it again. Then I was very unhappy! I
was crying! Then I said, ‘‘So you are starting me on this and
you would not even have told me? … Telling me what you are
doing is the minimum. This is my body and it is me that you
are doing things to.’’ So the nurse said, ‘‘I received orders.’’ I
couldn’t believe that I could be treated like that, that one could
be treated like that. So I said, ‘‘No, I don’t want it, not now.’’
Then the nurse was insisting. The midwife said, ‘‘Listen, she
has the right to refuse, it’s her body, at the end if she wants to
go back home she has the right to do so. The baby is doing well,
she is doing well, so if she says no, it’s no’’ (FTF, Valerie,
patient of a midwife).
In all cases, these feelings of lack of participation in
decision making resulted from a perceived lack of com-
munication and poor listening on the part of the hospital
staff.
After labor
Absence of information about the birth. This study
also brought to light the absence of ‘‘debriefing’’
(information and discussion) about the birth during
the postpartum period. This time is a period of
intense learning in the areas of breastfeeding and pro-
vision of infant care. The delivery itself was often
concluded or even dismissed quickly to concentrate
on the baby. Several women who gave birth in the
hospital setting told us that they felt the need to
understand better what had happened during labor,
BIRTH 37:2 June 2010
especially when complications occurred or a cesarean
section was done.
And I’m still stunned that I had a c-section. I’m waiting to go
and see my doctor. I go in 2 or 3 weeks, and I want to know
more. Like I guess they have to file reports, and I want to know
more about what exactly was in the report and why and … I
was always one of those people where I thought you got to do
what you got to do to have a healthy baby and to have a safe
delivery … But in the back of my head, it just never occurred
to me that I would have a c-section … I just, I don’t know why
I ended up with one (Kate, patient of an obstetrician).
The woman quoted above expressed a need to recon-
cile herself with the decisions that were made, to assure
herself that no other alternatives were available, and that
she had undergone an operation for the right reasons.
For several women in our study, their perception was
that no time was allotted to receive explanations or sim-
ply to get a response to their queries about their birth.
Discussion
This qualitative study was designed to determine how
information about pregnancy and birth, acquired prena-
tally and during the birthing process, influenced
women’s experience of birth. In line with the findings
from the Public Health Agency of Canada’s (PHAC)
recent survey on Canadian women’s maternity experi-
ence, we found that women seek and value information
from multiple sources (21). Based on different needs,
they value doctors for factual information, midwives for
information and reassurance, and friends and family for
their experience (21). We were surprised to find that
although the women in our study were very well
informed about pregnancy itself, those pregnant for the
first time found it difficult to determine how to enter into
the health care system. Even if the full range of birth
options were known, the problem of the limited supply
of midwives and capacity of birthing centers to accom-
modate women remain unresolved in Canada.
Our research also suggests that few women feel that
it is necessary to take an active role in selecting their
caregiver or birth setting in early pregnancy, perhaps, as
suggested by Sakala, because they assume that the stan-
dard care that they will receive is of high quality and in
their best interest (22). Women may be reluctant to ques-
tion medical authority. This finding is noteworthy in light
of the fact that our sample unintentionally included over-
representation from highly educated women. As sug-
gested by Simkin, at such a vulnerable time in their lives,
many women want to believe that ‘‘the doctor knows
best’’ and that the medical model of care will ensure a
safe outcome, regardless of whether or not they ‘‘person-
ally’’ know the people caring for them in labor (22).
165
Individual women’s attitudes, beliefs, and expecta-
tions about childbirth can vary significantly (3). Consis-
tent with other research findings, the study women who
were more conscious of their own beliefs and the differ-
ences between care providers seemed to choose their
birth pathway and birth setting based on the perception
either that pregnancy is a medical condition with risks,
or that it is a normal, natural process (3). It is clear that
if health care practitioners showed greater recognition
and transparency about the areas of agreement and dis-
agreement among themselves and other maternity care
professional groups, they could offer childbearing
women a valuable opportunity for dialog, education, and
more informed decision making (2,11).
Depending on the perspective of a woman and her
partner, fear can have a significant influence on women’s
desire for information and decision making prenatally
and during the birth. Fear of failure, loss of control, pain,
or the baby’s or mother’s own death can provoke anxiety,
which in turn can lead to a desire for medical interven-
tions or distrust in medical intervention (7,23). Our find-
ings showed that misunderstanding and misinformation
about birth decisions resulted in anxiety and distrust of
health care professionals and their medical interventions.
What role does prenatal education play in influencing
women’s birth expectations? Ideally, its primary aim
should be to increase a woman’s sense of confidence
based on obtaining accurate and realistic information to
enable her to make informed choices and feel in control
of her labor (23). Research has also found that control
and choice in childbirth relate to women’s greater satis-
faction and fulfillment from the experience, and greater
subsequent emotional well-being (5,15,16,18–20,23).
Control can also mean feeling confident enough to ask
for help or advice or to challenge a particular medical
decision (15). If women are not given information about
nonmedical methods of facilitating their birthing process
and coping with pain to enable them to make informed
choices, the epidural may be the only available option
for any semblance of control in childbirth.
Our findings corroborated Fenwick et al’s results,
suggesting that some women tend to be passive reci-
pients of information, allowing it to influence them
without seeking alternatives or seeing it as a tool for
their own involvement in decision making (3). Our find-
ings illustrated that midwives were far more likely to
provide women with choices to facilitate their involve-
ment in decision making than physicians, thereby
encouraging their clients to take a more active role in
their birth. We strongly believe that all women need to
be provided with information and choices not only dur-
ing pregnancy, but also during labor. The onus is on the
maternity health care community to reflect seriously on
how to improve their approach to informed decision
making with women and their families.
166
Ultimately, no matter how much information women
received, the most important issue was how they related
to their caregiver(s) during labor. In keeping with the
findings from other studies, the study women who had
continuous support from an experienced labor compan-
ion benefited most from being informed before labor
and, in turn, were offered more options and were better
able to avoid certain interventions (24). Although we did
not specifically explore the degree to which a quality
relationship with caregivers can help to empower
women during their birth, it was an underlying preoccu-
pation throughout our research process, and one that
deserves further exploration.
In the survey conducted by the PHAC, only about half
of all Canadian women reported their overall experience
of labor and birth as ‘‘very positive,’’ and fewer than
two-thirds of Canadian women were ‘‘very satisfied’’
with the information given by their health care practitio-
ners throughout their pregnancy, labor, birth, and imme-
diate postpartum period (21). Our research suggests that
women need to be provided with more information dur-
ing their labor, birth, and immediate postpartum. For
women whose birth expectations are not met, postnatal
‘‘debriefing’’ may be especially important (4,23).
Limitations
This study has several methodological limitations. The
two study samples differed: the French-speaking
Montreal sample was larger, and the women came from
settings that were somewhat different from the English-
speaking Vancouver women. Most of the women in the
study were also well educated, thereby limiting generali-
zation of findings to women of lower education levels.
Furthermore, the study design using open-ended inter-
views did not allow for clear and focused findings. The
format meant that women spoke very generally about
the information that they learned, for example, birthing
positions, epidural analgesia, episiotomy, and breast-
feeding, making it difficult to formulate specific compar-
isons based on care providers. Nevertheless, we believe
that the open-ended interview approach enabled the
study women to set the agenda based on their experience
and, consequently, to reveal some weaknesses in how
information is being shared and integrated into maternity
care in diverse settings in Montreal and Vancouver.
These limitations make it difficult to generalize from
this sample to other women in Canada.
Conclusions
The study findings, albeit neither surprising nor revolu-
tionary, provide evidence to reinforce and support the
BIRTH 37:2 June 2010
assertion that, despite positive changes in recent years,
family-centered maternity care in Canada still needs to
be improved. Our results showed that women have
access to numerous sources of information prenatally
but often do not know how to find the most appropriate
caregiver so that they work together toward achieving a
positive birthing experience. Women’s ability to use
their acquired prenatal knowledge to feel satisfied by
their birth experience continues to be undermined by a
system of care that does not prioritize women’s
informed choice. Further systemic change is required to
align maternity care with the needs of Canadian birthing
women and their families.
Acknowledgments
The authors are grateful to Nancy Duxbury for inter-
viewing of the Vancouver participants, to Nesrine Bes-
saih for coding of the data, and to the women of
Montreal and Vancouver for their generous contribution
of time to participate in the study.
References
1. Davis-Floyd RE. The role of obstetrical rituals in the resolution of
cultural anomaly. Soc Sci Med 1990;31:175–189.
2. DiMatteo MR, Kahn K, Berry SH. Narratives of birth and the
postpartum: Analysis of the focus group responses of new moth-
ers. Birth 1993;20(4):204–211.
3. Fenwick J, Hauck Y, Downie J, Butt J. The childbirth expecta-
tions of a self-selected cohort of Western Australian women.
Midwifery 2005;21:23–35.
4. Goodman P, Mackey MC, Tavakoli AS. Factors related to child-
birth satisfaction. J Adv Nurs 2004;46(2):212–219.
5. Simkin P. Just another day in a woman’s life? Women’s long-
term perceptions of their first birth experience. Part 1. Birth
1991;18:203–211.
6. Rothman BK. Women, providers, and control. JOGNN 1996;
25(3):253–256.
7. Klein MC. Contracting for trust in family practice obstetrics. Can
Fam Physician 1983;29:2225–2227.
8. Zwelling E, Phillips CR. Family-centered maternity care in the
new millennium: Is it real or is it imagined. J Perinat Neonatal
Nurs 2001;15(3):1–12.
9. Health Canada. Family-Centred Maternity and Newborn Care:
National Guidelines, 4th ed. Ottawa: Health Canada, 2000.
10. National Health and Welfare. Family-Centred Maternity and
Newborn Care. Ottawa: Institutional and Professional Services
Division, Health Services Directorate, 1987.
11. Reime B, Klein MC, Kelly A, et al. Do maternity care provider
groups have different attitudes towards birth? BJOG 2004;111:
1388–1393.
12. Charmaz K. Grounded theory: Objectivist and constructivist
methods. In: Denzin NK, Lincoln YS, eds. Handbook of Qualita-
tive Research, 2nd ed. Thousand Oaks, CA: Sage Publications,
2000:509–535.
13. Sandelowski M. Whatever happened to qualitative description?
Res Nurs Health 2000;23:334–340.
 BIRTH 37:2 June 2010
14. ATLAS.ti Scientific Software Development GmbH. ATLAS.ti 5.0.
Berlin: Rekenwonder Software, 2004.
15. Proctor S. What determines quality in maternity care? Comparing
the perceptions of childbearing women and midwives. Birth
1998;25(2):85–93.
16. Green JM, Coupland VA, Kitzinger JV. Expectations, experiences
and psychological outcomes of childbirth: A prospective study of
825 women. Birth 1990;17(1):15–24.
17. Hauck Y, Fenwick J, Downie J, Butt J. The influence of childbirth
expectations on Western Australian women’s perceptions of their
birth experience. Midwifery 2007;23:235–247.
18. Lavender T, Walkinshaw SA, Walton I. A prospective study of
women’s views of factors contributing to a positive birth experi-
ence. Midwifery 1999;15:40–46.
View publication stats
167
19. Brown S, Lumley J. Satisfaction with care in labor and birth: A
survey of 790 Australian women. Birth 1994;21(1):4–13.
20. Sandin-Bojo AK, Larsson BW, Hall-Lord ML. Women’s percep-
tion of intrapartal care in relation to WHO recommendations. J
Clin Nurs 2008;17:2993–3003.
21. Public Health Agency of Canada (PHAC). What Mothers Say: The
Canadian Maternity Experiences Survey. Ottawa: PHAC, 2009.
22. Klein M, Sakala C, Simkin P, et al. Roundtable discussion: Why
do women go along with this stuff? Birth 2006;33(3):245–250.
23. Gibbins J, Thomson AM. Women’s expectations and experiences
of childbirth. Midwifery 2001;17:302–313.
24. McGrath SK, Kennell JH. A randomized controlled trial on con-
tinuous labor support for middle-class couples; effect on cesarean
delivery rates. Birth 2008;35:92–97.