Hindawi Publishing Corporation
Nursing Research and Practice
Volume 2012, Article ID 648405, 10 pages
1School of Life Sciences, University of Sk¨ ovde, P.O. Box 408, 54128 Sk¨ ovde, Sweden
2School of Health and Medical Sciences,¨Orebro University, 70182¨Orebro, Sweden
3Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, P.O. Box 457, 40530 Gothenburg, Sweden
Correspondence should be addressed to Stina Thorstensson, email@example.com
Received 27 September 2012; Accepted 2 November 2012
Academic Editor: Katri Vehvil¨ ainen-Julkunen
Copyright © 2012 Stina Thorstensson et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
Support in labour has an impact on the childbirth experience as well as on childbirth outcomes. Both social and professional
support is needed. The aim of this study was to explore professional support offered by midwives during labour in relation to the
supportive needs of the childbearing woman and her partner. The study used a qualitative, inductive design using triangulation,
with observation followed by interviews. Seven midwives were observed when caring for seven women/couples in labour. After
the observations, individual interviews with midwives, women, and their partners were conducted. Data were analysed using
hermeneutical text interpretation. The results are presented with three themes. (1) Support as a professional task seems unclear and
of security. (3) Partner and midwife interact in support of the childbearing woman. The main interpretation shows that midwives’
supportive role during labour could be understood as them mainly adopting the “with institution” ideology in contrast to the
“with woman” ideology. This may increase the risk of childbearing women and their partners perceiving lack of support during
labour. There is a need to increase efficiency by providing support for professionals to adopt the “with woman” ideology.
Childbearing is a psychosocial event with an impact on the
woman and her partner. With their first child, they change
from being simply a couple to also being parents , and
prospective parents describe a need to be better prepared for
childbearing . A positive childbirth experience can be of
during labour has an impact on the woman’s childbirth
experience . The childbirth experience is complex, with
many related concepts; however, experiencing a sense of
control seems to be an important contribution to a positive
experience [6, 7]. The childbearing woman needs to sur-
render herself to the birthing process during labour while
retaining an element of control [8, 9].
Professional support from the midwife has been de-
scribed as providing the childbearing woman with the
strength needed to face the challenge of giving birth without
losing control [8–10]. When support during labour is con-
tinuous, it also reduces the risk of medical interventions, as
emergency caesarean section or regional analgesia which are
less prevalent, and labours are shorter .
Support during labour could be offered by the child-
bearing woman’s partner, friend, family members, and pro-
fessionals . Support is described as an interactive pro-
cess that is affected by the persons’ age, experience, and
personality as well as by the environment [12, 13]. Social
support from the partner or professional support from the
midwife are different; however, both are important for the
childbirth experience . In the meta-analysis by Hodnett
et al. , the effect of support is greater when offered
by a person not employed by the hospital and not a
member of the social network of the childbearing woman.
In recent years, a nonprofessional group called doulas offer
2Nursing Research and Practice
continuous labour support to childbearing women and their
partners. Research has shown that doulas offer intrapartum
support that the midwives seem to be incapable to offer
in terms of presence and continuity . Nonsupportive
attitudes within organizations and lack of resources such
as time or knowledge are described as hindering health-
professionals in offering labour support to women [16–19].
The environment, such as conventional or alternative birth
setting or leadership, will also affect the efficiency of the
support offered and how it is perceived by the childbearing
women [13, 20, 21]. Furthermore, women perceiving lack
of support during labour may experience intense fear of
childbirth in subsequent pregnancies .
In Sweden, the midwife assumes responsibility for care
offered to women during normal pregnancy, childbirth,
and the postpartum period. When complications occur, the
midwife will consult an obstetrician who will take over
responsibility for the medical care of the woman. During
labour, most of the professional support will be the responsi-
bility of the midwife; however, little is known of midwives’
perceptions and experience regarding this part of their
work. Furthermore, some midwifery students in the USA
and Sweden have stated that their tutors did not explicitly
address offering continuous labour support [23–25], which
made midwifery students feel uncertain of their professional
supportive role . Support during labour is important for
the childbirth experience and for childbirth outcomes ,
and support could be considered an important part of the
midwifery profession . Therefore, the aim of this study
was to explore professional support offered by midwives
during labour in relation to the supportive needs of the
childbearing woman and her partner.
The present study used an inductive approach with qualita-
tive data collection methods using triangulation . Data
were collected through observation , which was followed
by individual interviews  with the midwife, the woman,
and her partner within a week of the observation. Data were
analyzed using hermeneutical text interpretation .
This study was conducted in a labour ward in the southwest
of Sweden. This labour ward has around 3,000 births per
year and serves urban, suburban, and rural areas. Women
with both uncomplicated and complicated pregnancies are
admitted to the labour ward. The ward is organized with a
all incoming communication (i.e., when women in labour
call for advice or when they arrive at the labour ward).
This organization allows other midwives to care for the
the phone or dealing with newly-arrived women in labour.
The ward has care memoranda stating that the staff should
strive to achieve good communication with the childbearing
woman to create security and trust, and that the staff should
strive to be present with the woman as much as possible.
Special attention should be given to first time mothers;
however, the midwives have to care for more than one
woman simultaneously if the workload is heavy.
3.1. The Physical Environment in the Labour Rooms. The
labour rooms were quite similar in terms of environment.
There was a front room that was delimited from the labour
room by a curtain, which could be drawn to block the view
from the door if anyone should open it. In the labour room,
there was a hospital bed placed in the centre. Along the right
side were a wash basin, some stools, and a shelf for weighing
and measuring the babies. There were three windows in
each room, and curtains varied in colour between the
rooms. There were two or three plants on the windowsill.
A computer, an electric foetal monitor, a nitrous oxide
apparatus, an arm chair, and a bed side table were on the
left side of the room. When the observer entered the room,
a couple’s luggage could have been put on the window sill
or placed on the baby cot. Male partners typically wore their
The midwives wore more or less the same outfit, a blue dress
or shirt together with blue trousers.
The participants for this study were midwives (n = 7) at
the labour ward and the childbearing women (n = 7) and
their partners (n = 7) that these midwives cared for during
the observation. In order to get a variety of professional
and personal experience, the participating midwives were
purposely selected  out of years in the profession and
experience of childbirth. The women and their partners were
selected from being cared for by the participating midwives
during the observation. All participating midwives were
labour wards and other areas of midwifery practice. Five of
the seven women the midwives cared for in this study were
first time mothers and two were having their second child;
education from secondary school to university education.
Their partners were four first time fathers and three were
having their second child; they varied in age from 25 to
36 years and education from secondary school to university
education. All couples lived together, they were ethnically
Swedish, and their living conditions varied from apartments
in towns to villas in the countryside.
5.1. The Observations. Access to perform the study was given
by the head of the clinic as well as head of the ward.
Midwives that had given their consent to participate in the
study were contacted by the first author (S. Thorstensson)
to agree on a day for the observation. These participating
midwives asked the childbearing woman and her partner
for their consent to participate, and a written consent was
obtained. The observations started with the first author (S.
to five hours or if the baby was born. The observer remained
Nursing Research and Practice3
observation notes were taken continuously. A checklist
to capture details and remind the observer of areas of
importance was made ; however, the observations were
otherwise unstructured. The interaction observed included
verbal and nonverbal communication, such as eye contact,
touch, and where the midwife was focussing her attention
. Verbal communication was generally summarised but
sometimes noted as quotations The general feeling of the
room (as experienced by the observer) and other reflections
of the observer (S. Thorstensson) were also noted, as well
as time, a description of the room, and the clothes the
within a couple of days from the observation and during this
and with reflections of the observer specifically noted.
5.2. The Interviews. The observation notes formed the basis
of the interview with the midwife and with the woman and
partner. Consequently, when the observation was completed
and before the interviews, the observation notes were read
through and notes of interest for the aim of the study were
made. The interview with the midwife would also contain
general questions about the responsibility of the midwife in
relation to support during labour, and the needs of the woman
and her partner. The interviews with the woman and her
partner would also contain overall questions about their
experience of giving birth, being present when the baby was
born, and what support needs they themselves or their partners
were given time to express their thoughts in their own words
; when necessary, questions were posed to encourage
the interviewees to expand their descriptions. Midwives were
interviewed in private within 24 hours after the observation
on the labour ward. The midwives were on duty; however,
they were released so they could leave for the duration of
the interview. Interviewing the women and their partners
was done between one and a half and seven days after
the birth. The interviews were mostly performed on the
the parents’ home for practical reasons. The interviews were
digitally recorded and transcribed verbatim.
Observation and interviews were all collected for one
author (S. Thorstensson) performed both observations and
interviews. Continuous discussions and reflections about
data collection and quality of data was done between the first
(S. Thorstensson), second (A. Ekstr¨ om), and fourth (E. H.
Wahn) authors, resulting in improvement and amendment
some general questions and interview techniques. All obser-
vation notes and interviews were transcribed before analysis
began. Data was collected from October 2009 to June 2010.
Observation note transcripts and interview transcripts were
analysed using hermeneutic text interpretation to explore
the woman and partner. “Hermeneutic” means understand-
ing through interpretation. Interpretation is important for
necessary for this understanding . The relation between
the whole and the parts and the movement in between (the
“hermeneutic circle”) is important. Understanding the parts
can only be done through understanding the whole, and
the whole can only be understood through understanding
the parts. Hermeneutic text interpretation is characterized
by its focus on the receiver . The interpretation was
done in close dialogue with the text and keeping an open
mind. Our preunderstanding from working as midwives in
labour wards (S. Thorstensson; A. Ekstr¨ om; I. Lundgren; E.
H. Wahn), in antenatal care (S. Thorstensson; E. H. Wahn),
and as teachers for midwifery students (S. Thorstensson;
A. Ekstr¨ om; I. Lundgren; E. H. Wahn) could assist when
interpreting the text. However, our preunderstanding could
also obscure the meaning of the text and hinder in seeing
something new. To keep a dialogue and ask questions to the
text, keeping an open mind, and continuously reflect about
our preunderstanding, assisted when interpreting the text
. One way to identify whether the preunderstanding is
dominating the result is to look for parts in the data and in
the result that are conspicuous or surprising .
The interpretation started by reading the observation
understanding of professional support by midwives’ during
labour within each observation and linking this with the
interviews with the midwife, the woman, and her partner.
Then, the texts were read through again, and notes were
made and questions arising were noted. Answers to the
questions were then looked for in the data. The analysis
continued interpreting the text in parts by identifying
strophes of the same meaning and getting an idea of the
horizon of the text and the horizon of the interpreter .
The questions asked to the text were as follows: How can
we understand midwifery professional support during labour?
How will midwifery professional support present itself during
labour? How will the woman and/or her partner experience
these situations?, and What supportive needs does the woman
or her partner express during labour? The findings were
through to search for a new whole (a main interpretation),
moving from the whole to the parts and back to the whole
again . The main interpretation was structured at a more
abstract level and the concepts “with woman” and “with
institution”, as described by Hunter , were used in order
to explore professional support during labour in relation to
the needs of the woman and her partner.
Before data collection began, information about the study
was sent to antenatal clinics to inform parents about the
study so they would be prepared if they would be asked to
participate. Observing during labour is a delicate situation,
and there is a risk that the woman, her partner, or the
midwife could experience the observer as an intruder. Both
the midwife and the couple were informed that they could
4Nursing Research and Practice
ask the observer to leave at any time had her presence
been disturbing to them. There could also be situations
arising during the observations that demand action from
the observer from an ethical standpoint, and the observer
(S. Thorstensson) had mentally prepared for that. However
during the observations in this study, no such situation
occurred. Ethical approval for the study was obtained from
collection began. The study was conducted in accordance
with the Declaration of Helsinki (1964).
The findings are presented in three themes. Support as a
professional task seems unclear and less well defined than
medical controls; midwives and parents express somewhat
different supportive ideas about how to create a sense of
8.1. Support as a Professional Task Seems Unclear and Less
Well Defined than Medical Controls. The midwives attention
to supportive needs varied and seemed to be based in their
own idea of the purpose of care during labour and on
their own personal experience of childbirth. Further, the
midwives paid obvious attention toward medical control of
the physiological process (i.e., planning and informing when
the next vaginal examination would be performed). When
in the room, the midwife would give the woman her full
attention; however, the midwife’s reason for entering the
room seemed primarily to be in order to perform tasks such
as medical controls.
The midwife sits beside the woman with her
fingers on the woman’s belly. The contraction is
over, the midwife checks the blood pressure and it
is now somewhat lower than before. The midwife
says that this tells her that the epidural has started
to take effect. The midwife takes the trolley for
epidural anaesthesia out through the door, but
first she puts a blanket over the woman. The
midwife says to the woman, “I will send in the
auxiliary nurse to check your blood pressure”.
(Observation notes, couple, second child).
The midwife’s main focus of attention seemed to be
on control of the physical process and offering support in
between. However, the midwife would also sometimes focus
on offering support to the woman and her partner in
handling the labour process, and then her attention at
performing tasks such as medical controls would be placed
more in between. While medical controls seemed to be
planned and performed with consistency, supportive needs
sometimes seemed to be addressed with uncertainty or not
at all. This uncertainty could emerge from the idea described
by the midwives that there is a right (and, consequently, a
wrong) way to do things in relation to supportive needs.
This idea seem to stem from a lack of knowledge in meeting
supportive needs, which leaves the midwives with only their
own experience (i.e., their own childbirth experiences) when
offering support to the woman or her partner.
Contraction—the woman breathes nitrous oxide.
The midwife turns to the computer and writes.
The woman puts her hand over her lower back.
She let’s go of the nitrous oxide and takes a deep
breath. (Observation notes, woman, first child).
Midwife; Well, it is difficult to ... how can one
know how ... // ... I could imagine that most
perhaps want to be left alone ... // ... yes, I do
not want other people to fuss with me when I have
a contraction ... (Interview, midwife).
Different needs of the woman and the partner were
observed during labour. The need for energy or to visit the
toilet seems clear, unambiguous, and well defined. These
needs were actively met by the midwives during labour.
However, some needs, such as the woman’s need for reas-
surance or the woman (or her partner) being worried,
seem ambiguous, vaguely expressed, and less well defined.
These needs sometimes seemed difficult for the midwives to
understand; consequently, they were not always met.
The woman says, “how bad will it hurt?” The
midwife does not answer or react to her question.
(Observation notes, woman, first child).
Meeting needs of reassurance seems to demand that
the midwife interprets what the woman’s actual need was,
rather than offering direct action or answers. When observed
to address concerns or provide reassurance, the midwives
used information or general terms of reassurance; however,
they sometimes seemed uncertain or hesitant. Nevertheless,
when midwives in the interviews described clear ideas of
supportive care in labour; this appeared to have helped—for
example, in meeting insecurity by offering reassurance—as
the following excerpts illustrate.
The woman has a contraction. The midwife sits
... // ... Another contraction. The woman is
wife is holding the woman’s knee. (Observation
notes, couple, first child).
Midwife; Every time she had a contraction, I held
on her knee or something only to make her feel
I am calm and sort of think that this is ok ... I try
to communicate that ... (Interview, midwife).
Woman: ... when she had her hand on my
knee, that I remember because it felt really good
(“good” stated with emphasis) it was during the
contractions that she held her hand on my knee
and it felt really good ... but the belly I did not
notice; I guess it was that she wanted to feel the
contraction ... but when she had her hand on
my knee ... that felt good (“good” stated with
emphasis) ... (Interview, woman first child).
Nursing Research and Practice5
The midwife describes a clear intention to communicate
reassurance to the woman through touching her knee. The
intention the midwife describes for her nonverbal action
seems to influence the woman’s experience of this action
Where the midwives place their attention seems to affect
that were ambiguous and vaguely expressed. There seemed
to be more consistency in performing medical controls than
in offering support to the woman and her partner. This
difference seems attributable to the midwives varying in
certainty or knowledge when addressing supportive needs.
8.2. Midwives and Parents Express Somewhat Different Sup-
portive Ideas about How to Create a Sense of Security. To sup-
port a sense of security for the women and their partners, the
midwives offered information continuously during labour.
This information was mainly practical (e.g., if leaving, when
the midwife would return) or medical (e.g., how an epidural
works). The midwives described in the interviews that
credible information was crucial for the parents to trust the
midwives. Women and their partners stated that continuous
information created a sense of hope and security.
Interviewer: ... could you give me some example
of something that the midwife did that made you
Woman; no ... well ... yes ... they said what they
were going to do ... // ... and that sort of she said
that she would come back, and when she said she
would come back she did that also ... (Interview,
woman, first child).
When the midwives informed parents about procedures
not directly in connection with labour, or gave information
that was contradictory to what the woman or her partner
believed to be true, this information was not considered
supportive. Information was also described by the midwives
as a way to prepare for medical intervention, though with
a need to balance when and how much information should
be offered, since information can be calming but can also
be worrying. Information could also be indirect, such as
offering spinal anaesthesia that would only last three hours,
indicating to the woman/couple that the baby would be
born within this time, even if the midwife did not say this
One aspect of support to create security is to invite the
woman to participate through awaiting her readiness before
performing examinations and this was done by all midwives.
The midwives also invited the women and their partners to
participate in decisions. However, this invitation sometimes
seemed somewhat dubious, since the woman, for example,
could find it quite hard to actually say no to the midwife
leaving the room. Even if the midwife technically presented
her proposal as a suggestion, it seemed more as information
and not as an invitation to participate in the decision.
The midwife asks the couple, “is it ok if I go in and
out of the room a little?”
(Observation notes, couple, first child).
Midwife: well ... what I think about then is
that they in some way should get a chance to be
involved in the decision in some way ... that I do
not just leave and they do not know how I had
thought ... (Interview, midwife).
The midwives’ presence in the room seemed to be sup-
portive in creating a sense of security. For the woman to be
able to look up and meet the eyes of the midwife could be
reassuring. As a consequence, when the midwife leave the
room, she would take away some of this sense of security.
When the woman was very secure with her partner, she
described not being so aware of the midwife leaving the
room. However, the partner described a sense of responsibil-
ity when left alone with the woman during labour, and this
seemed to have created insecurity for the partner.
Partner: They told you exactly what to do, and
they were very helpful the whole time, so it felt
good when they were present. It was worse when
they left sometimes, they ran in and out in
between, and that (made me) nervous (he laughs)
... // ... well, then (I) felt a bit nervous, then I
thought, “well then, I am on my own, then” ...
(Interview, partner, first child).
The midwife could also be more continuously present in
the room and wait for the contractions alongside the couple.
In this case, her absence would not create insecurity in the
same way and her absence was described as if she was still in
Partner; well ... she went out and then it was just
to continue as if she was still there ... (Interview,
partner, first child).
The midwives did not explicitly describe their own pres-
ence in the room as important, even if they mention that
offering time is important to support creating security dur-
ing labour. Even when the woman has an urge to push and
she wants the midwife to stay in the room, the midwife could
chose to leave if another task was deemed as important and
the midwife felt certain that birth was not imminent.
Woman: ... well it was that last period when I
started to feel the urge to push, and she had this
other patient to report, and so ... so then I got a
bit frustrated that she disappeared; I did because
then I felt that now the baby is on the way and
then it was still two more hours (she laughs) really
... but ... it did feel a bit ... then it was a bit scary
that she left actually ... (Interview, woman, first
Midwife: Eh ... I knew she had good support from
her husband and that she would not give birth
right now and I had this other woman that I had
to attend to ... // ...
6Nursing Research and Practice
Interviewer: How do you think she experienced
this that you left there?
Midwife: She and many with her will first feel
some panic because of their urge to push, and they
do not want to be alone—but if I explain again so
that she can understand ... // ... it was the same
with her or with them, they understood, and she
did not ring the bell, but she was secure in this ...
When the midwife can joke or make small talk, the
couple seems to perceive that the midwife is in control of the
and her partner. Women described how being in labour
made them feel different and that this could be frightening.
If the midwife then made small talk, this created a sense
of the usual, and the woman regained a sense of her usual
self. The midwives were observed using jokes and small talk
in interacting with the women and their partners. When
interviewed, the midwives said that this was because it is
so nice to small talk a little or I am a joking kind of person.
The midwives seemed a bit uncertain as to whether joking is
appropriate in the situation; they do not describe it explicitly
as a supportive strategy.
There seemed to be somewhat different ideas of sup-
port to create a sense of security. The midwives and the
women/couples agreed on continuous credible information
being important when supporting to create a sense of
security. That the midwives presence in the room or making
small talk and joking would support to create a sense of
security did not seem to be entirely acknowledged by the
midwives. However, to the woman and her partner, the
presence (or absence) of the midwife, as well as joking, and
small talk, seemed important to their sense of security.
8.3. Partner and Midwife Interact in Support of the Woman.
The midwives and partners were observed to interact when
offering support to the woman. This interaction could look
almost like a “dance”, where the midwife would suggest
something and the partner would act accordingly in support
of the woman, or the partner would act and the midwife
would confirm his action.
The midwife says to the woman, “it seems as if
you can easier handle your contractions when you
are standing” ... // ... (Another contraction). The
woman breathes through the contraction, she is
grimacing and she holds the partner’s hand. The
contraction is over. He says immediately: “ok, now
you get up”. The midwife also says, “it is good to
be upright and walk, the second best is to sit in
the armchair”. (Observation notes, couple, second
If the partner is a first time parent, the midwife may
need to offer more guidance on how to support the woman
than if he was expecting his second child. The midwife then
invited the partner by asking him what he thought about his
role during labour. When invited by the midwife, the partner
when the partner and the woman do not agree. One example
of this is if the woman feels she is handling the contractions,
but her partner has difficulty in handling her having pain.
says, “what do you think, should you try nitrous
oxide?” She answers, “I feel rather ok”. He replies,
“You do not look ok to me” ... // ... He asks the
midwife, “is it time to think about anaesthesia
now?” The midwife replies, “yes if you (she turns
to the woman) feel that you need something more,
then it is time for that now” ... (Observation
notes, couple, first child).
This supportive situation calls for a delicate “act of
balance” for the midwife, in differentiating between the
actual needs of the woman and the demands or needs of
her partner. The midwife may also interact with the partner
in support of the woman, as well as the physical process.
Helping the woman to relax could be one way of doing this.
The midwife says, “Do you want to lie down?”
(Another contraction) The woman says, “ouch
... ouch” She breathes through the contraction.
Then she lies down in bed. The midwife says to
her partner, “You can lay down behind her if we
pull up the “gate” so you do not fall out of the
bed”. // ... He lies down behind her in bed and
holds her. They talk between contractions ... //
... The midwife asks, “is the pain most in front?”
The woman is nodding. The midwife places a
warm cloth over the woman’s symphysis and belly
and then pulls the blanket over them both. The
midwife looks at them and says, “this looks quite
cosy”. (Observation notes, couple, first child).
The woman could be very tired and vague about her
needs; in these cases, the midwife could interact with the
partner to reach a contact with the woman. The partner
could ask the midwife questions on behalf of the woman.
However, it was also observed that sometimes the midwife
did not interact with the partner in support of the woman.
The midwife could enter the room with her attention toward
the woman and tasks needing to be performed. Then the
midwife could place herself between the woman and her
partner as if he was not present. This could seem to make
the partner feel uncomfortable, as if he was in the way and
did not have a place or function in the room. However,
if the partner feels that the most important thing is that
the midwife takes good care of his wife, then he may not
experience this as awkward. This situation may be easier to
handle for a partner expecting his second child.
The midwives would address the partners need for drink
about the partner and what needs he might have. The needs
mentioned were the need for participation and information.
However, one midwife concluded that “he has the same need
as her ... it is just that he is not in pain ...”.
Nursing Research and Practice7
The midwives’ seemed to vary in interacting, meeting,
and supporting the partners’ need to act supportive towards
the woman. There seemed to be a continuum where the
partner could be seen, on one hand, as someone who is not
really involved in the situation, or, on the other, the partner
and support to fulfil his part.
Midwives’ supportive role during labour could be under-
stood as being mainly affected by the midwife adopting the
“with institution” ideology in contrast to the “with woman”
ideology, as described by Hunter . These ideologies
should not be seen as stressing or neglecting medical safety
but merely as an illustration of differing perspectives in
relation to professional support. In the “with institution”
ideology, professional support is unclear, vague, and based
on the midwives’ personal experiences. In the “with woman”
ideology, support is clearly offered within the professional
place their attention only at tasks, with a consistency in
performing medical controls, it could be understood as
the midwives adopting the “with institution” ideology with
an attention to efficiency, only focusing on physical safety
and risk-management. Supportive needs that are more
ambiguous or vaguely expressed could then be understood
as unimportant for the midwife, which could lead to clearly
expressed needs, such as the need for food or drink, being
actively met, while ambiguous needs, such as the need for
reassurance, being addressed with uncertainty or not at all.
This uncertainty could be reinforced by the idea described by
the midwives that there is a right and, consequently, a wrong
way to do things in relation to supportive needs. Uncer-
tainty in addressing ambiguous supportive needs could be
understood as the midwives lacking knowledge about how to
address supportive needs.
On the other hand, when the midwives adopt the “with
woman” ideology, their focus would be to form and sustain a
relationship with the woman/couple. To focus a relationship
could be understood as making the midwife more aware of
and prepared to meet both clear and ambiguous supportive
needs of the woman or her partner. The somewhat different
ideas about how to support to create security during labour
could be understood as a contradiction between the woman
and her partner expressing a wider range of supportive needs
to experience a sense of security in labour, while the mid-
wives adopting the “with institution” ideology would mainly
focus on information and tasks to perform. Being present in
the room with no actual task to perform apart from offering
support, or to joke or make small talk, could be understood
as inefficient under the “with institution” ideology. However,
when adopting the “with woman” ideology it would be
efficient for the midwife to be present and to joke and
make small talk in order to form and sustain a relationship
with the woman and her partner. This could be understood
as the “with woman” ideology being more adequate in
meeting the wider range of supportive needs described by
the woman and her partner, than the “with institution”
ideology. In the “with institution” ideology, the woman’s
partner is present as support to her, and their becoming
parents is not acknowledged as important, since emphasis is
only on task performance and risk-management. However,
midwife could be understood as addressing both the woman
and her partner as becoming parents and to interact with the
partner in support of the woman during the birth process.
The most important finding in this study was that pro-
fessional support, offered by midwives during labour, is
affected by the ideology adopted by the midwives. The
adopted ideology will affect which supportive needs of the
woman/couple the midwife will address during labour.
Midwives, women, and their partners describe somewhat
different supportive ideas about how to create a sense of
security during labour. The midwives, when adopting the
“with institution” ideology, will only focus on efficiency and
mainly offer information though women and their partners
express a wider range of supportive needs to experience
a sense of security during labour. Labour is a complex,
changeable, and flexible process , and the physiological
process can be disturbed if the woman does not feel secure
enough during labour [35, 36]. To feel secure during labour,
the woman needs presence of supportive persons that can
offer security in the process [9, 37, 38]. Offering support
during labour needs to be almost continuous in order to
be effective, which could, theoretically, be understood as
decreasing stress reactions and imposing security in the
labouring woman . Findings of this study suggest that
supportive actions were less well defined as professional
tasks than task, such as medical controls, and the midwives,
relying mainly on personal experience, seemed uncertain
in meeting ambiguous supportive needs. This uncertainty
could be understood as the “with institution” ideology
imposing knowledge of supportive actions as not important.
Knowledge could be silenced or not acknowledged as
imbalance , which could lead to midwives adopting the
ideology “with institution”, perceiving lack of knowledge to
offer support. Lack of knowledge in offering support during
labour has been described elsewhere . Thus, it may be
due to the domination of the ideology “with institution” that
supportive actions as forming and sustaining relationships
are important, but hidden, aspects of care in labour .
Findings of this study suggest that midwives vary in how
they interact with the partner in support of the woman
during labour, which could be understood as the midwives
adopting different ideologies. The partner most often wants
to offer support to the woman during labour [41–43], and,
overlook “with institution” or actively meet “with woman”
the partners’ need for guidance and support. Findings from
this study described that the partner expressed uncertainty
when being left alone to support the woman during labour,
while the midwives did not entirely acknowledge their pres-
8Nursing Research and Practice
partners report feelings of helplessness and anxiety during
labour [44, 45]. These feelings of anxiety could impose
feelings of being left out if the father was not supported ,
and professionals being present was described by the partner
as important support .
Findings from this study also suggest that it could be
complicated for the partner to handle his own reactions to
the woman’s pain, as well as supporting her during labour.
These results emphasise that the partner needs guidance to
fulfill his supportive part [41–43, 47, 48]. Hence, when mid-
wives adopt the ideology “with institution”, with emphasis
only on task performance and risk management, they could
be less efficient in meeting supportive needs of the partner
than when midwives adopt the “with woman” ideology.
The “with institution” ideology only focusing on effi-
ciency could be understood as prompting that midwives
should be able to attend to more than one woman in labour
when necessary though actually attending the one woman
in labour when possible. However, the main interpretation
of this study suggests that the differing ideologies propose
different focuses, such as a focus to meet supportive needs of
the woman or her partner, or a focus on task performance.
the differing ideologies in response to the workload of the
ward. On the other hand, continuous labour support has
been shown to be efficient in reducing medical interventions
and to increase the chance of a positive birth experience.
However, this support seems more efficient when offered
by nonprofessionals . Perhaps professionals more often
adopt the “with institution” ideology, as the midwives in this
study mainly did, which may lead to professionals failing to
offer efficient labour support as result of this study suggest.
Women describe the experience of midwives as uncaring
during labour , or women experience lack support
from the midwife during labour, which sometimes results
in intense fear of childbirth in a subsequent pregnancy
. In relation to the findings of this study, it could be
suggested that, when midwives adopt the “with institution”
ideology, their ability to meet supportive needs decreases.
That will increase the risk of women experiencing lack of
support during labour. Support in labour has an impact
on the childbirth experience , and six percent of women
that reported dissatisfaction with care during labour were
unsatisfied with interpersonal care . Perhaps organizing
for professionals to be able to adopt the “with woman”
ideology would be more efficient when both medical and
care outcomes are concerned, since this could lead to less
women experiencing lack of support during labour. How-
ever, adopting the “with woman” ideology seems to present
midwives with more emotional labour  in relation to
colleagues and the organization than when adopting the
“with institution” ideology, suggesting that support within
the organization is essential for midwives to adopt the “with
The strengths of this study include the method used, which
offers an opportunity to enter deeply into the supportive
role of midwives. The triangulation in data collection 
provided both observed data and the thoughts and reflec-
tions of both midwives and the women/couple that they
must be interpreted in relation to the context : in this
study, a single labour ward in Sweden. On the other hand,
both the midwives and the couples they cared for during the
observations varied in experience, parity, age, and education
The fact that the results are contextual does not mean that
it has no meaning in other contexts; however, they must
be related to the new context, which is in line with the
hermeneutic circle .
having an impact on the situation under study. However, the
observer tried to move as little as possible in order not to
disturb the midwife or the couple. Neither the midwives nor
the couples felt disturbed by the observer when questioned
about it in the interviews. When using hermeneutic text
interpretation in analysing data, our preunderstanding could
assist as well as hamper us when exploring  midwives’
supportive role during labour. Analysis was done with an
preunderstanding through reflection .
Midwives’ supportive role during labour was affected by
them mainly adopting the “with institution” ideology rather
than the “with woman” ideology. Adopting the “with insti-
tution” ideology, the midwives place their attention mainly
on task performance and risk-management, which increased
the risk that supportive needs of women or their partners
during labour would not be met. When adopting the “with
woman” ideology, it seems that a wider range of supportive
the midwife. However, to meet the sometimes-contradictory
needs of the woman/couple and the requirements of the
institution might give rise to emotional strain for the
midwife. Hence, the organization in which the events take
place needs to increase efficiency by providing support for
the chance of the supportive needs of women and their
partners being met.
Conflict of Interests
The authors declare that they have no conflict of interests.
This study was supported by the Skaraborg Institute for
Research and Development and the School of Life Sciences
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