‘Doing what the Romans do in Rome’ was an expression raised by one of the midwives following workplace culture and disregarding women’s birth choices. Midwifery practice in South Africa caters for a culturally diverse ethnic groups of childbearing women. Culturally appropriate care highlights the importance of including women in decision-making concerning their birth preferences including maternal positions during labour. Women’s right to choose their maternal position and cultural preferences during labour has been overlooked, leading to poor maternal healthcare provision and negative birth experiences.
In this article, the researchers aimed to describe and explore midwives’ perspectives on culturally appropriate care to support maternal positions during the second stage of labour.
Midwives working in the maternity ward in a public hospital in South Africa.
A qualitative descriptive design using individual interviews was used to collect data. The participants were selected using the purposive sampling method. The study population comprised 20 midwives who volunteered to participate in the study. Data were transcribed manually and analysed using thematic analysis.
The four main themes are as follows: (1) Caring for women from various ethnic groups, (2) midwives disregard women’s beliefs and culture, (3) midwife personal cultural attributes and (4) midwifery unit workplace culture.
The authors concluded that culturally appropriate care towards the women’s choices of birth position during the second stage of labour should form an integral part of the midwifery care rendered.
The need for ‘culturally appropriate’ maternity care services is core to the World Health Organization’s (WHO) strategy for improving maternal and new-born health and ending preventable maternal mortality.
Minority ethno-linguistic or religious childbearing women often have limited access to maternity care services than the rest of the population.
According to Mselle,
The right of choice of birth position, freedom of movement during birth and continuous support during the first and second stage of labour has been overlooked in various midwifery settings.
‘Lack of culturally appropriate care and intervention to the women’s needs is a global concern and has been noted as barrier’.
A qualitative, exploratory and descriptive research design was used to explore and describe the culturally appropriate care to support women’s choice of maternal position during labour. This approach enabled the researchers to gain more in-depth understanding of the phenomenon studied.
The study was conducted in a public hospital premises situated in Pretoria in the City of Tshwane Metropolitan district. The selected hospital operates 24 hours a day, and the services provided are low-risk maternal healthcare services that include antenatal, intrapartum and postpartum care. Overall, the hospital caters for rural and urban areas surrounding the hospital.
The study took place in the maternity ward of the hospital. This is a 30-bedded ward with eight ante-natal beds in one cubicle (two admission beds, two isolation, two first-stage and four second-stage/delivery beds located in private individual rooms). The labour ward offers services to low-risk childbearing women, without any obstetrical complication or high-risk conditions (such as pre-eclampsia). On average, about 300–350 women give birth monthly in the maternity ward.
The study population includes midwives (registered with the South African Nursing Council [SANC]) offering maternal health services to women from various ethnic backgrounds such as Tshwana speaking, Shona, Indian, Somalian, Venda, Zimbabwean, among others. These women come to the labour units for intrapartum care, and they have cultural practices and traditions that they follow (e.g. Muslims prefer consuming halaal food and some herbal drinks for protection during labour, women from African countries prefer squatting during labour, etc). Other low-risk childbearing women come as referrals from local clinics within the sub-district of Tshwane, and some are referrals from the nearby high-risk hospitals. The staff ratio is about eight midwives during the day and night shift who are present in the ward, which is in line with the SANC regulation.
The researchers were working at the labour ward during the time of data collection in 2018. Permission was obtained from the hospital authorities as part of the recruitment strategy. The researchers utilised purposeful sampling to select the participants. The population of the study comprised 20 midwives who met the inclusion criteria and agreed to participate. All the midwives selected for the study were registered with SANC per the inclusion criteria (refer to
Demographic characteristics of the participants.
Variable | % | |
---|---|---|
Advanced midwife | 7 | 35.00 |
Professional nurse | 13 | 65.00 |
Community service | 2 | 10.00 |
20–29 | 7 | 35.00 |
30–39 | 7 | 35.00 |
40–49 | 3 | 5.00 |
50–59 | 2 | 10.00 |
60–69 | 1 | 0.05 |
Female | 20 | 100.00 |
< 1 | 2 | 10.00 |
1–5 | 9 | 45.00 |
6–10 | 4 | 20.00 |
11–20 | 2 | 10.00 |
The identified midwives were then approached for participation in the study. Explanation was given to the participants regarding the nature of the study. Those who showed interest to participate in the study were also informed that their participation is voluntary. The characteristics of the population in this study were professional nurses with midwifery qualifications integrated during the comprehensive nursing degree/diploma training or 3-year diploma course and advanced midwives with a speciality in midwifery. The midwives were responsible for assisting women during the first and second stages of labour.
The study was conducted over four months during June–September 2018. Individual semi-structured, face-to-face interviews were employed to explore the midwives’ perspectives on culturally appropriate care to support maternal positions during the second stage of labour. First, the researchers scheduled suitable interview dates with the midwives for data collection. The interview took place in a quiet private room in the labour ward without disrupting the daily routine of the midwives. The researchers were flexible to work around the availability of the midwives. Labour wards are very busy; thus at times, the researchers had to wait for midwives to complete the duties first and hand over the women to other midwives while doing the interview. Most of the interviews were done at the end of the day shift at 19:00 after staff changes, due to the hectic and busy periods of the labour ward.
Informed consent was obtained before conducting the interview. Each interview lasted between 30 and 45 min duration. The interviews were held in English. The researchers used the semi-structured interview guide to aid the interview. Probing and clarification were performed to gain a full understanding of the comments and responses during the interview. Throughout the data collection, the researchers kept a journal to write field notes. Also, an audio recorder was used once consent was gained from participants to record the interviews. The interviews were ended once data saturation was reached when no new information was emerging from the interviews.
The data analysis followed eight steps of the Tesch analysis method.
Measures of trustworthiness refer to ensuring the truth value of the research findings by Guba and Lincoln (1985 under reference 21 of Polit and Beck). The researchers ensured truthfulness through authenticity, credibility, confirmability and transferability.
Ethical clearance to conduct the study was granted by the University of Pretoria, Research Ethics Committee, Faculty of Health Sciences before commencement of the actual research (ethical clearance certificate: 133/2018). Permission was obtained from the Department of Health and the Chief Executive Officer of the hospital in Tshwane.
The researchers maintained the following ethical principles that guided the study: Beneficence, respect for human dignity and justice as outlined in the Belmont report. Informed consent was sought from the participants before the data collection commenced. Participants were informed of their right to partake or withdraw from the study at any given point. Participants were informed that should they express any discomfort during the interviews; additional psychological support would be made available to them.
The analysis process yielded the following three themes as indicated in
Themes and sub-themes that emanated from results.
Themes | Sub-themes |
---|---|
Theme 1: Barriers to culturally appropriate care in maternity service | Sub-theme 1.1: Ethno-linguistic barriers |
Sub-theme 1.2: Uncooperative behaviour of women during birth | |
Theme 2: Midwives imposing own personal adapted cultural beliefs on childbearing women | Sub-theme 2.1: Midwives’ own adopted culture |
Sub-theme 2.2: Disrespect of tradition and culture by midwives | |
Sub-theme 2.3: Midwives’ preconceived fears regarding childbirth | |
Theme 3: Midwifery Unit workplace culture | Sub-theme 3.1: ‘Following what the Roman’s do in Rome’ |
The barriers to culturally appropriate care in maternity services have been identified as the main theme. The midwives in the study indicated that it is challenging for them to care for women from various ethnic groups. The following sub-themes also emanated from the main theme: ethno-linguistic barriers and due to not being able to understand the childbearing women language and cultural beliefs of the following women for example (women from Somalia or women from Zimbabwe speaking Shona), these are unfamiliar languages to the midwives. The consequence of ethno-linguistic barrier becomes and results in uncooperative behaviour of the women during labour also becomes a barrier to provide the cultural appropriate care. The following quotes support the main emergent theme.
The midwives in the study indicated that they experience ethno-linguistic difficulties during birth in which they are unable to understand what the women are saying especially when dealing with the various ethnic groups of women who utilise the maternal healthcare services in South Africa. Lack of understanding of these women’s language hampers the midwife’s ability to provide care that is in line with the womens’ cultural preferences regarding birth and maternal positions to adopt during the second stage of labour:
One of the midwives reported on their experience that:
‘I had an experience one time with a Shona women, we could not communicate due to language barrier. This woman was also not following instructions given. It’s easy for the midwife to use lithotomy/supine position because; this woman was wrestles and I could not convince her to use other birth position such as squatting …’ (Participant 5, registered nurse/midwife, 32 years old)
Another midwife indicated that they even try to use a translator or non-verbal gestures when dealing with women who do not understand English or their native languages:
‘We get a lot of women coming from other African countries who don’t understand English to deliver at our unit. You cannot instruct someone who does not understand you. So with lithotomy position it’s safe because, once they look up maybe you the midwife can look at a woman during birth and use gestures to instruct her. With other birth positions like squatting, they might be looking down and not understanding what you are saying.’ (Participant 11, registered nurse/midwife, 31 years old)
Another view regarding women’s culture came out of the interviews:
‘We deal with women from East Africa who come with those traditional herbs mixed in bottle. We cannot allow that in the ward and others even tell you that from my culture I am used to squatting because that is how I have been taught. We as midwives we cannot allow that.’ (Participant 4, registered midwife, 24 years old)
Notably, the issue of language and communication difficulty came as a barrier for midwives to provide culturally appropriate care.
The second sub-theme that emanated from the findings was the uncooperative behaviour of women during birth, experienced as a result of a language barrier with the women from different ethnic groups. The midwives in the study told that most of the time women do not cooperate during labour. Lack of cooperation makes it difficult for them to try and think of utilising other maternal birth positions. The quotes below support the sub-theme identified.
One of the midwives indicated that:
‘The challenges we are facing as midwives have to deal with uncooperative patients, especially from the women from other countries, and sometimes with the increased workload and high patient influx we are not able to use other birth positions …’ (Participant 6, registered nurse/midwife, 29 years old)
Another midwife raised an assumption that childbearing women have cultural beliefs and practices and have their own preferences during labour, but midwives are not able to cater for the cultural preferences. The language barrier meant that there was a lack of understanding between midwives and childbearing women:
‘The women will tell you that in their culture, they prefer to squat. Most of these women from African countries are uncooperative patients who fear childbirth pain; they start lifting buttock during labour, while of lithotomy position. The others even close their legs during labour, but it is a better position because you can see the perineum, how will they be able to co-operate on position such as squatting.’ (Participant 11, registered nurse/midwife, 31 years old)
It is noted that midwives are not rendering culturally appropriate care due to the challenges resulting from the lack of cooperation from most of the women from other ethnic groups because of the language barrier.
The findings of the study identified the second main theme, which indicates that midwives impose their own cultural attributes on childbearing women. The midwives in this study disregarded the childbearing women’s cultural preference concerning the maternal position. The following sub-themes emerged to support the main theme including the conundrum of own personal cultural beliefs and midwives’ preconceived ideas and fears regarding labour.
This sub-theme describes midwives’ adopted culture (
‘I personally prefer using the supine position, as it is a position I prefer. Moreover, I developed the culture and norm for using the lithotomy position, It is a position I prefer irrespective of what the women prefers of chooses …’ (Participant 6, registered nurse/midwife, 29 years old)
The midwives acquired this norm in the wards where they practised their midwifery skills. They learned the cultural practice and followed the practice done in the ward:
‘The lithotomy position is a position most of us are using somehow it’s like a norm in the ward. We have never tried other positions, I mean everywhere I worked before as a student it’s a position that is always used …’ (Participant 3, registered nurse/midwife, 30 years old)
Midwives follow their own norms and disregard the women’s norms:
‘The other factor that contributes to midwives not using other birth positions is because of comfortability. You know the religious position the lithotomy position is mostly done for the comfort of midwife, they’re not much concerned of patients comfort but the midwife needs to be more comfortable with position …’ (Participant 20, advanced midwife, 40 years old)
It is evident from the findings that midwives found an existing culture in the maternity wards and adopted the culture of following the norm in the ward and disregard the cultural beliefs that women have concerning their childbirth process.
The participants reported disrespect or disregard for the traditions and culture of women who come to give birth. They acknowledged that they do not recognise the traditions and norms but instead encourage the westernised, evidence-based medicine that is provided in the hospital. The following quotes support the sub-theme.
One of the midwives told that women would indicate that they prefer to squat in their own preferred culture:
‘The women will tell you that in their culture, they prefer to squat [
Some midwives would disregard the women’s choices and beliefs:
‘We always found the lithotomy being used here, and no we never give the woman a choice of birth position.’ (Participant 1, advanced midwife, 36 years old)
‘We only use the lithotomy position because we are used to this position …’ (Participant 13 advance midwife, 60 years old)
The midwives further mistreat the women, by indicating that some women are not well educated. This indicates that some women are not treated equally due to their educational background:
‘The women are not literate enough to know their rights or maybe the information that needs to be given to them. To be honest we don’t even inform them at all of the birth positions available, they are not given an option because we are not going to go with her option. We only use birth positions that suit us not the patient …’ (Participant 1, advanced midwife, 36 years old)
The third sub-theme to support the main theme indicates that midwives have preconceived fears concerning labour and that affects them being able to support the women’s choices and cultural beliefs concerning birth. Some of the midwives verbalised their cultural beliefs, and some of the preconceived fears have a role to play on them not allowing the women’s own choice of birth position and not rendering culturally appropriate care to support the women’s choices.
One midwife indicated that the fears she have are a barrier to her providing culturally appropriate care and to give preference to the women’s choice of maternal position:
‘I think we fear of the unknown of what if something goes wrong, we need to break the culture of putting woman on one position …’ (Participant 9, registered nurse/midwife, 24 years old)
Another midwife indicated that other fears included unfamiliarity with other birth positions:
‘Suppose the woman is giving birth on the commode [
One of the midwives was worried about safety as well:
‘The lithotomy position is safe, isn’t that we want a happy mother and an alive baby at the end of the day. So you have to weigh the options do you want to deliver this woman looking down and not understanding you. Not knowing what will happen? I am unsure about the other positions …’ (Participant 11, registered nurse/midwife, 31 years old)
Finally, one of the other midwives indicated the necessity of receiving training to alleviate the fears as one of the suggestions for them to support the women’s choices:
‘Well it can start with alleviating the fear midwives have of being resistant to change and receive more education, skills and training on other birth positions showing them that there is actually no harm of using alternative birth positions on the mother and the baby and the culture associated to women preferences …’ (Participant16, registered nurse/midwife, 30 years old).
The last theme that contributes to the midwives’ lack of culturally appropriate care is the workplace culture followed in the maternity unit. This is a culture already followed in the ward, irrespective of the women’s preferences or cultural beliefs concerning maternal positions during the second stage of labour. Institutional norms and practices were reported as barriers that limited the midwives from promoting culturally appropriate care or involving the women in the decision-making processes of their labour. Sub-theme 3.1 supports the main theme as identified.
This sub-theme emanated from the findings from most of the midwives, which indicated that they are following the workplace culture already found in the maternity unit.
One of the midwives indicated that this is a workplace culture that they have been accustomed to:
‘It is more of a developed culture and norm for us to utilise the lithotomy position, It is a position I prefer …’ (Participant 6, registered nurse/midwife, 29 years old)
‘We don’t see other birth positions being utilized in our working institutions, thus we developed a culture in the ward of using the supine position, despite the preference of the woman …’ (Participant 4, community service/midwife, 24 years old)
‘The other factor that contributes to midwives not using other birth positions is because of comfortability. You know the religious position the lithotomy position is mostly done for the comfort of midwife, they’re not much concerned of patients comfort but the midwife needs to be more comfortable with position …’ (Participant 20, advanced midwife, 40 years old)
Some midwives even gave a phrase to describe the culture they are now being accustomed to in the wards, which is ‘Do what the Romans do’. The culture we adopted from the midwifery unit, as expounded by some of the midwives:
‘I place the woman on lithotomy position because it is what I found being done in the unit. I think it is a culture of this unit and I know I was taught on other birth positions during studies but I have never practice it. I guess we are just joined what the Romans do in Rome, so I adopted the culture …’ (Participant 9, registered nurse/midwife, 24 years old)
Another midwife decided to disregard the theoretical lessons learnt during midwifery training and followed the norm in the labour ward:
‘I only studied other birth positions in school during the third year, in midwifery as an undergraduate. But when you get to practice [
The purpose of the study was to explore the midwives’ perspectives on culturally appropriate care to support maternal positions during the second stage of labour. The key findings of the study indicate that currently culturally appropriate care is not rendered in the maternity units, due to barriers such as organisational culture and the personal adapted beliefs of the midwives that prevent them to honour the culture of the childbearing women. The study argues that maternal healthcare professionals need to be more aware of the cultures and subcultures of the childbearing women across all ethnic groups and understand the women’s preferences and choices regarding the maternal position in order to abide by the WHO strategy for culturally appropriate care.
Midwives should not impose their own adopted culture regarding the way of doing things and disregard the women’s choices during labour. It is evident from the midwifery curriculum that the midwives are taught all the various birth positions that can be used. The maternity guidelines in South Africa
In countries such as Ethopia,
The last theme identified the workplace culture acting as an obstacle to the provision of culturally appropriate care in midwifery units. Many studies indicate that the midwifery unit should promote humanising caring standards and promote RMC. The current findings of the study are in synergy with the recent systematic review by Bradley.
In summary, women cognitively evaluate the experience of labour differently. Some women remember their birth experiences in detail for a lifetime. Therefore, their birth experience does affect how they perceive birthing (Simkin 1991, 1992).
Global perspectives from the WHO published guidelines and policies on the provision of culturally appropriate care still need to be implemented in clinical settings. Furthermore, changes to incorporate culturally appropriate care need to be carried on and supported from the macro-level hospital management to ensure it is implemented in the micro-level maternity wards. Recommendations can be made to re-align the protocols to ensure that women are given a choice during labour on their preferred maternal position as it is in line with the women’s cultural beliefs and norms (perhaps include language interpreters as well). Bottom-up approach needs to be followed for changes to the current workplace culture of restricting women to assume other birth positions and restricting women’s movement should start at the micro-level so as to influence care and render culturally appropriate care.
At the micro-level, in-service training can be provided on cultural beliefs that women have during labour, and this will raise cultural awareness about women from various ethnic groups who are not familiar to the midwives in South Africa.
Guidelines for education and training on culturally appropriate care need to be implemented from the higher education institutions. Culturally appropriate care and relation to scientific evidence-based midwifery care interventions should be developed for the institution under study. Other institutions may benefit through the dissemination of findings.
Further research can focus on the experiences of women from various ethno-linguistic groups regarding culturally appropriate care.
The study provided a broader understanding and insight into maternal healthcare services provided to women during the first and second stages of labour. The findings of the study also enhance support and encourage midwives to be more aware of their practice and advocate for them to be supportive and provide culturally appropriate care to women.
The limitation of the study is that the findings cannot be generalised because the study took place in a specific district hospital in Tshwane, Gauteng with a specific population of interest. Although the study was conducted only in one hospital, the findings of the study can be transferable to other public hospitals within and outside the district.
The findings of this study demonstrate that midwives need to be aware and provide care that considers the childbearing women’s cultural preferences and practices regarding maternal position during labour and ensure the provision of culturally appropriate care to achieve optimal maternal and neonatal health as recommended by the WHO recommendation. Currently, the maternal healthcare is not tailored towards culturally appropriate care and that affects the women’s utilisation of skilled birth facilities.
The authors would like to acknowledge the Department of Health for permission granted, and the University of Pretoria for ethical approval of the study. The authors also acknowledge the maternal and child committee as part of the UBUNTU community model, the National Research Fund for the grant to perform the study and the Chief Executive Officers who granted permission to conduct the study. All Maternal Healthcare Managers, Operational Managers and midwives participated in this study.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
M.R.M. conducted the study and drafted the manuscript. M.D.P. and V.B.-P. supervised the project, provided support during the study and edited the article.
The National Research Fund provided financial assistance through a grant to perform the study.
The raw data used to support the findings of this study are included in the article.
The views and opinions expressed in this article are those of the authors and do not reflect the official position of any affiliated agency of the authors.