Towards the promotion of normal birth : action research in a tertiary maternity unit in Singapore

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Background Strategies to promote normal birth are a priority in many high-income countries, where the increasing escalation of caesarean section is an important health concern. There are serious implications associated with caesarean section (and the consequential decrease in normal births) for childbearing women and their families as well as maternity services. Limited information, however, is available on effective and sustainable approaches to address this issue. In particular, research on strategies to promote and support normal birth in tertiary maternity units, where most women in high-income countries give birth to their babies, is scarce. The Promotion of Normal Birth (PoNB) study focused extensively on working towards the promotion of normal birth and changing the culture within a tertiary maternity unit in Singapore. The study was the country’s first hospital-supported effort aimed at promoting normal birth and reducing caesarean section rates. Aims The PoNB study was designed to explore how the promotion of normal birth could be encouraged and embedded in the culture within a hospital maternity unit. The study aims were to: (1) promote maternity care practices that support normal birth in a tertiary maternity unit in Singapore; (2) encourage participation among providers of maternity care (midwives, nurses and obstetricians) and consumers (women, who use the service, childbirth educators and doulas), in working together (co-creation) as a ‘team’ through systematic problem-solving processes to promote normal birth; (3) develop a culture within the tertiary maternity unit that is supportive of normal birth; and (4) develop understanding to inform future developments in the promotion of normal birth that might be able to be applied in other similar settings (i.e. tertiary maternity contexts). Method This work was developed and implemented within an Action Research (AR) framework, guided by the philosophy of critical social theory. Six midwives (including the primary researcher) and two obstetricians from the hospital formed the Normal Birth Collaborative (NBC) action research workgroup. Thematic content analysis of focus groups and descriptive statistical analysis of surveys as well as clinical outcomes informed the action research. In total, over 600 participants (maternity care providers, women, childbirth educators and doulas) were involved in the study. Findings An AR framework enabled maternity service staff and consumers to engage in a collaborative process that informed the successful identification, planning and evaluation of a number of initiatives to promote normal birth in the maternity unit. Improvements were made when addressing a number of key characteristics of labour ward culture that were identified as important areas for change. In particular, the Maternal Positions for Labour initiative (PFL) was successful in raising awareness about the identified need to provide an appropriate environment and birthing aids so that women could be supported to move around in labour and adopt positions of their choice. Focus groups with the NBC workgroup members as well as PFL surveys showed that both women and staff members appreciated the opportunities afforded by the intervention. Implications for practice The findings from the PoNB study have the potential to impact significantly on efforts to promote normal birth and improve maternity care in Singapore, as well as in similar organisations internationally. The study reinforces the importance of collaboration between maternity service providers and consumers in all phases of changing practice.
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