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Title
Beyond the numbers: A phenomenological analysis of women's childbirth experiences in
Spain’s evolving healthcare system.
Authors
Roser Palau-Costafreda RM, PhDc a,b,c,*
Sonia Nar-Devi RM b
Maria Gil-Poisa PhDb,c
Amaia Pajares Manso RM d
Ana España Vela RM d
Noemí Obregón Gutiérrez RM, PhD e,f,g
Ramon Escuriet RM, PhD h
Mireia Julià PhDb,c
Ariadna Graells-Sans PhDc b,c
Affiliations
aBiomedicine Programme, Department of Experimental and Health Sciences, Universitat
Pompeu Fabra, Barcelona, Spain
bESIMar (Mar Nursing School), Parc de Salut Mar, Universitat Pompeu Fabra - affiliated,
Barcelona, Spain
cSDHEd (Social Determinants and Health Education Research Group), IMIM (Hospital del
Mar Medical Research Institute), Barcelona, Spain
dFundació Hospital Sant Joan de Déu de Martorell, Martorell, Spain
eParc Taulí University Hospital, Sabadell, Spain
fParc Taulí Research and Innovation Institute Foundation (I3PT), Sabadell, Spain
gUniversitat Autònoma de Barcelona, Sabadell, Spain
hDirectorate General of Health Planning, Ministry of Health of the Government of Catalonia,
Barcelona, Spain
Corresponding author:
*Roser Palau-Costafreda, Escola Superior d’Infermeria Hospital del Mar. C/ del Dr. Aiguader,
80, Ciutat Vella, 08003 Barcelona.
Twitter: @roser_palau
Email: rpalauc@esimar.edu.es
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NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
Abstract
Background: Childbirth is a transformative experience, yet a considerable percentage of
women worldwide encounter negative birth events, affecting maternal wellbeing and mental
health. The choice of birth setting significantly impacts outcomes, with midwifery-led units
often associated with lower intervention rates and higher satisfaction levels. The recent
introduction of midwifery-led units in Spain presents a unique opportunity to explore the
impact of this model within a medicalized healthcare context.
Aim: To capture the depth and diversity of women's voices, understanding factors
influencing their perceptions of childbirth experiences following the introduction of the first
midwifery-led unit in the Spanish Healthcare System.
Methods: A qualitative study with a phenomenological approach within the constructivist
paradigm. Four focus groups were conducted including nineteen women who gave birth in a
hospital with both an obstetric and a midwifery-led unit.
Findings: Three main themes were identified; ‘Shaping birth expectations’, highlighting the
influence of cultural and social contexts on women’s childbirth expectations; ‘The childbirth
essentials’, incorporating fundamental characteristics related to the model of care; and
‘Navigating the protective factors’, considering the pivotal role of midwives in delivering
compassionate and respectful care.
Conclusion: These findings offer valuable insights into childbirth experiences, advocating
for a transformation of the medicalized healthcare system in Spain through the integration of
midwifery-led units. By prioritising women's voices and addressing systemic inequalities,
healthcare policymakers can enhance maternal care practices and foster positive childbirth
experiences for all women.
Keywords
Childbirth expectations; Childbirth experience; Maternity care; Midwifery care;
Patient-centred care; Qualitative method
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Introduction
Childbirth is a deeply personal and transformative experience encompassing physical,
emotional, and social dimensions that shape the identity and memories of those involved1.
The significance of childbirth as a multifaceted experience resonates globally, influencing the
well-being of both women and society at large. The World Health Organization (WHO)
underscores the importance of accessible, acceptable, and high-quality healthcare2,
emphasising a ‘positive child experience’ as a crucial outcome indicator for women
undergoing childbirth3. A comprehensive definition of a positive childbirth experience
emphasises feeling supported, in control, safe, and respected, highlighting the role of
provider interactions4. Positive childbirth experiences not only contribute to women’s
psychosocial well-being, but also hold the potential to empower and transform individuals5.
Despite global efforts to prioritise respectful maternity care6, evidence suggests that a
substantial percentage of women worldwide experience childbirth as a negative or traumatic
event, with prevalence ranging from 4% to 45%7, 8. The repercussions of such negative birth
experiences are profound, closely linked to disrupted maternal psychological and emotional
outcomes, including postpartum anxiety, post-traumatic stress disorder and postpartum
depression7, 9, 10. These consequences extend to maternal self-esteem, the ability to bond
with the infant, breastfeeding rates, and the overall transition to motherhood11, 12.
The choice of a birth setting significantly influences a woman's birth experience13. While the
majority of births in high and middle-income countries occur in a hospital, research indicates
that midwifery-led units (MLUs) or birth centres, are associated with reduced rates of
medical interventions during labour and childbirth when compared to traditional obstetric
units (OU)14,15 and higher satisfaction rates13, attributed to feelings of comfort, active
involvement, and increased sense of control14,16. These findings indicate the importance of
considering diverse birth settings when evaluating the overall experience of childbirth.
Spain's approach to childbirth care is undergoing a transformative shift through the
implementation of MLUs in its National Health System17, 18. This approach presents a unique
opportunity to explore the impact of this on women's birth experiences in Spain, given the
country's prevailing medicalized healthcare environment19. Despite recognizing the
significance of factors like continuity of care, midwifery-led models, patient-centred care,
provision of information, and participation from decision-making13, 14, 20, these elements have
not been fully integrated across the Spanish Healthcare System, leaving the complexity of
childbirth care in Spain only partially understood. Exploring professional practices and
various factors influencing birth experiences within this context will contribute valuable
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insights, advancing our understanding of the implications of this model for maternal
well-being.
The aim of this study is to capture the depth and diversity of women's voices, understanding
the interplay between the factors influencing their perceptions of the childbirth experience
following the introduction of the first MLUs in the Spanish Healthcare System. The findings
aim to provide useful information to healthcare providers and policymakers to promote
positive childbirth experiences.
Methods
Design
This study employs a qualitative methodology and the research design is situated within the
constructivist paradigm, offering an ontological approach rooted in the understanding of
realities through situated and subjective construction. Phenomenology has been selected as
a theoretical and methodological framework facilitating a deep exploration of childbirth
experiences within their socio-cultural context21. The philosophical alignment of
phenomenology with midwifery22 accentuates key concepts including care, presence,
concern, interpersonal dynamics and therapeutic caring connections.
Setting
This study was conducted in a community public Hospital in XX, Spain, with an average of
650 childbirths annually. The hospital offers two distinctive birthing settings: a traditional OU
and a MLU. Although the MLU is separate from the OU, it has access to the same hospital
facilities.
The OU follows a biomedical model of care, staffed by obstetricians, anaesthetists,
paediatricians, and midwives. It is equipped to handle high-risk pregnancies and
complications during labour and birth. The OU features advanced medical equipment,
including emergency surgical facilities. Pain management options such as epidurals are
readily available. The care approach in the OU involves standardised medical protocols and
interventions, including inductions, caesarean sections, and assisted births.
In contrast, the MLU, introduced in December 2017 as the first of its kind in the Spanish
Healthcare System, is managed exclusively by qualified midwives and operates
autonomously within the hospital. The MLU focuses on women with uncomplicated
pregnancies and aims to provide a home-like, calming environment. Medical interventions
are limited, with an emphasis on physiological birthing practices. Facilities in the MLU
include a birthing pool and other natural pain relief methods. The MLU follows a
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biopsychosocial model of care with a women-centred approach, featuring individualised care
plans that encourage active participation of the mother in the birthing process.
Participants and sampling
Purposive sampling was employed to ensure diverse participant backgrounds. Inclusion
criteria were: (1) Spanish-speaking women; (2) residing in Spain; (3) aged 18 years or older;
(4) with uncomplicated pregnancies; (5) who had given birth either in the MLU or the OU.
Exclusion criteria comprised: (1) births occurring before 37 weeks; or (2) high-risk
pregnancies.
Participants who were already part of the BirthingBetter study were identified and
subsequently invited to participate in this research by a member of the research team via
telephone. Following this initial contact, detailed information and informed consent forms
were sent to them via email. Participants were given time to consider their involvement
before being invited to join one of the four focus groups, scheduled between 4 and 9 months
postpartum.
Out of 25 women that were invited to the focus groups, 22 consented to participate, and
three withdrew last-minute changes in family arrangements. Comprehensive data, including
background information and birth details, were systematically collected through online
questionnaires. The characteristics of the participants are summarised in Table 1.
Data collection
Data were collected through focus groups, selected for their capacity to create rich,
interactive discussions. The focus groups were conducted to resemble postnatal or
breastfeeding support groups, reflecting community practices where women openly share
their childbirth experiences. Focus groups were preferred over individual interviews to
provide a comfortable, supportive environment, enhancing participants' willingness to share
personal and sensitive experiences. This method is particularly effective in uncovering
cultural norms and collective attitudes toward childbirth that might not surface in individual
interviews.
Nineteen women participated in four focus groups conducted between March and April 2022.
Each session was facilitated by a midwife and observed by an additional researcher who
took field notes. To accommodate postpartum women and minimise travel, sessions were
held virtually via Zoom23. Participants consented to audio and video recording for
transcription. The sessions, conducted in Spanish and Catalan, lasted an average of 80
minutes, ranging from 68 to 102 minutes. The interview guide (Table 2), developed based on
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literature and input from women and healthcare professionals, included five open-ended
questions exploring childbirth experiences and related factors. Transcripts were initially in
Spanish and then translated into English. Any real names from mothers or healthcare
professionals were fully replaced with pseudonyms. Once data saturation was achieved
during the focus groups, no further groups were conducted, ensuring the data's depth and
richness were sufficient.
Data analysis
Following the collection and verbatim transcription of all narratives, a thematic analysis was
conducted, drawing on established methodologies24 and using the Atlas.ti program. To
ensure the robustness and precision of interpretation, three members of the research team
(XX, XX, and XX) initially performed independent analyses. The accuracy of the code
grouping process underwent validation through discussions involving the other researchers,
resulting in a consensus on the categorization of codes into themes and subthemes, also
minimising biases linked with the professional background. This collaborative approach
allowed for the triangulation of information and results, enhancing the reliability of the
findings. Themes were derived from the data, and any discrepancies that arose were
resolved through consensus among the team members. In the final phase of analysis, three
overarching themes with their subthemes were formulated and are presented in Table 3.
Ethical and quality considerations
Ethical approval (registration number XX) was obtained from the Ethics Committee of XX.
Anonymity protection was prioritised due to the study's sensitive nature and small sample
size. Data was pseudonymized and securely stored by the lead researcher, in accordance
with the current data privacy regulations. Participants received a participant information
sheet detailing the study and were given a two-week period to decide on participation. They
signed a consent form to confirm their voluntary involvement. Participants were assured the
right to withdraw without consequence, even during focus group discussions, ensuring their
decisions were well-informed and voluntary.
3. Results
The childbirth experiences of women were grouped into three themes: ‘Shaping birth
expectations’, ‘The childbirth essentials’, and ‘Navigating the protective factors’. Within these
3 main themes, 10 subthemes were identified (Table 3).
Shaping birth expectations
Cultural and social factors
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Participants commonly recognized the profound impact of childbirth expectations on the
overall birthing experience. The childbirth experience was significantly influenced by the
alignment or misalignment of these expectations, which could determine whether the
experience was viewed positively or negatively. The shaping of these expectations appeared
deeply rooted in cultural and social contexts. Women particularly emphasised the role of
external influences in shaping their expectations, attributing this phenomenon to the
diminishing visibility of authentic birthing experiences within the community. For example,
relying on external sources such videos and peer discussions to form their childbirth
expectations:
‘I've read all the birth stories, watched all the videos. [...] I would ask my friends about it. I
like it. But, in real life, we don't have that many chances. I haven't seen a birth yet, you
know? I have never seen a vaginal birth more than the ones that I’ve seen on YouTube. I
mean, it's something we talk about a lot, that we prepare a lot for, but, in reality, until you
find yourself in that situation, you've never been present in one.’ (P2, OU)
Moreover, the societal association of natural childbirth with strength placed significant
pressure on women, compelling them to exhibit resilience and endurance during labour.
Participants frequently expressed feelings of guilt, perceiving themselves as having 'failed' if
they deviated from societal expectations of a natural birth. Participant 15's narrative
illustrates this internal struggle, as she initially aspired to a natural birth in the MLU but
ultimately underwent labour induction in the OU:
‘And always, when I think about it, I sometimes feel a bit guilty. Sometimes I think 'what if,'
'what if I had done it,' 'what if…'. Well, all those thoughts, right? that mothers always
have... I don't know. I panicked, and it was like I couldn't handle it, you know? I was
already worn out, and no, I couldn't... I couldn't.’ (P15, OU)
Previous obstetric experiences
For some participants, a pivotal moment was linked to giving birth for the first time. The birth
of their first child became transformative, shaping expectations for subsequent pregnancies,
particularly those marked by dissatisfaction. The proactive approach stemmed from a strong
desire to avoid reliving challenging memories associated with previous childbirths:
‘I was coming from an experience that was not respectful with my first daughter. I did the
birth plan, everything, we prepared everything with my partner, and well, that day it just
stayed there on a shelf. [...] Everything I didn't want to happen, it happened. I had bad
memories... and my intention was not to have more children. But this time I wanted to
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have a good memory, and that's why I came [to the MLU], and... and it was very, very
beautiful and respectful.’ (P7, MLU)
Knowledge, interaction and healthcare accessibility
The accessibility and comprehension of the healthcare system emerged as another crucial
determinant in shaping childbirth expectations and influencing decisions regarding birthing
environments. One participant referred to the unequal information regarding the options for
place of birth:
‘Information is something that we should have from early in pregnancy. Because, even
when you go for check-ups, unless you don’t actively seek information, you might remain
unaware of places like this [MLU] and alternative ways of giving birth.’ (P9, MLU)
Furthermore, the ongoing interaction with the healthcare system played a significant role in
shaping expectations. For example, external factors, including medical opinions, seemed to
contribute to the gradual formation of mindsets and childbirth expectations:
‘My girl was born big, well, 3.8 kilograms. There are much bigger babies. But, from the
very beginning, in the community centre, they told me I was having a very big girl and that
I wouldn't be able to deliver naturally. There was no support anywhere. [...] They gradually
undermined our confidence, and although we appeared strong externally, at every
medical check-up, we found words or phrases that didn't sit well with us.’ (P10, OU)
The childbirth essentials
Women consistently articulated the essential elements that contribute to enhancing their
overall satisfaction. In this theme, we describe these elements within the two distinct models
of care—the MLU and the OU.
One to one care
In the MLU, participants usually recounted experiences of one-to-one care provided by a
dedicated midwife during labour. This personalised attention significantly contributed to a
sense of support and individualised care throughout the birthing process:
‘Raga, the midwife, was there accompanying me and supporting me at all times. And it
was somewhat thanks to her that I was able to have a birth that I would have never
imagined, it was really beautiful. [...] The last few hours were very intense, but at the
same time, I felt very supported at all times. I remember a moment that was really cool,
you know? It was during the shift change of the midwives, but Raga, who had been with
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me throughout, didn't want to leave me alone, you know? So the midwives were there,
and it was the moment of delivery, and they were all encouraging me. [...] I remember this
moment as really beautiful, and everyone was there, waiting for the baby to be born. [...] I
felt very supported with the encouragement I really needed at all times.’ (P6, MLU)
Conversely, participants in the OU described instances where they felt a lack of support and
a desire for more personalised attention. Participants expressed frustration with the workload
of midwives, as the example of this participant:
‘And what if I could have done a bit of biomechanics to see if the baby had positioned
well? But what happened? After getting the epidural, there was no one with me either. [...]
The midwives were extremely busy; there were three or four other moms arriving
suddenly at midnight, and it was 1 am. I was there alone, waiting to see when my time
would come.’ (P1, combined care)
Pain relief strategies
Within the MLU, participants appreciated the holistic approach to pain relief, acknowledging
the diverse needs of women during childbirth. The model's commitment to addressing
individualised pain relief needs was exemplified in Participant 17's encounter with a midwife
named Claire:
‘Claire, who was wonderful, [...] seemed like Mary Poppins because she was pulling out
all kinds of resources. She would come in and say, 'come on, why don't we try the
electrodes,' 'why don't you try the ball,' 'why don't you shower,' 'why...' And all the time like
that, right? And I was drawing strength, I don't know where from.’ (P17, combined care)
Conversely, in the OU, participants perceived a more limited availability of pain relief
strategies, primarily centred around epidural-based options, with reported limitations in
accessing alternative methods like showers, bathtubs, or birthing pools. Participant 13's
experience highlighted the perceived constraints in the model:
‘I couldn't use the shower because another woman was using it, and I asked for a bathtub
or the birthing pool. They told me it wasn't possible in the labour ward.’ (P13, OU)
Privacy and dignity
Concerning privacy and dignity, participants, emphasised the utmost significance of
preserving dignity, privacy, and autonomy throughout the childbirth experience:
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‘We were super well; we have very, very good memories. We were accompanied all day
by Hannah [the midwife]. Since we entered the room, she set up the entire place as if we
were at home. With soft light, salt lamp light, aromatherapy... I really valued having
privacy. Especially when you have to be there for many hours. Being able to be calm,
knowing that no one will enter the room, except for her [the midwife]. That also helped me
a lot to be calm and to be able to be like home.’ (P8, Combined care)
The transition between rooms was noted by women like Participant 13, who articulated a
moment of discomfort in the transitional zone. The disparity in ambiance was highlighted as
important for maintaining a sense of privacy.
‘I went up to the room [antenatal ward], and they told me that when the contractions were
continuous and strong, I should let them know, and I could come down [to the OU]. So,
when I thought it was time I asked to come down. There was no dim lighting, I mean, it
was a cold hospital room with bright white light that was blinding me. There were people
walking up and around, and I felt a bit defenceless.’ (P13, OU)
Furthermore, Participant 16 reinforced the significance of ambiance in cultivating a sense of
intimacy when talking about what was essential for her to have a positive birth experience:
‘I think that privacy is important. The privacy that you have, right? In the room, in the
entire environment. I believe that for giving birth successfully you need this privacy… the
low light, minimal noise. So, you can enter into your own world. I think that it is important.’
(P16, Combined care)
Respectful care
There was absolute consensus among participants on the significance of respectful care on
their childbirth experiences. This can be seen through the words of this participant, that
expresses a deep appreciation for the respect received:
‘For me, the most crucial aspect was the respect I felt throughout, and the support. [...] I
felt like I was in harmony, right, with the midwives and such. Above all, I felt very
respected. It really bothers me when they infantilize me; it makes me very angry. I cannot
tolerate it. This feeling of 'I am the doctor, and I know, and you don't'. That paternalistic
attitude, 'I am big, and you are small,' I can't stand it. For me, this is the main aspect.’
(P15, combined care)
Reflecting on the limited emphasis on the woman's experience and emotions within the OU,
participants reported a sense of diminished respect and attention to their emotional
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well-being. The following participant vividly describes her experience upon going to theatre
for a caesarean section:
‘As I entered the operating room, I was... It was a drama, feeling nauseous, trembling. In
the operating room, no one said anything to me. Until at one point, I said, poking my head
through the surgical screen, 'Hey, today is a very important day for me.' I didn't say it to
seek attention at that moment, but because I wondered if someone would look into my
eyes at any point. That really bothered me because it felt like me on one side, [of the
surgical drape] and another world going on the other.’ (P2, OU)
Navigating the protective factors
Meeting “elements of value” in care
During childbirth, despite facing unmet expectations, women emphasised “elements of
value” that triggered positive emotions or acceptance of the experience. Participant 10
summarised several of these “elements of value”, encompassing patient-centred care,
individualised attention, emotional support, accompaniment, and compassionate care,
despite undergoing a caesarean section:
‘I ended up having a caesarean section, but I was very clear about the birth plan. I was
able to discuss it calmly, and the medical team there was very pleased because they told
me it was the first caesarean they had done with such respect. They lowered the curtain; I
could see the baby coming out. We did skin-to-skin immediately. My husband was there;
he could record everything. They turned off the lights, which they had never done before.
I asked them to turn off the lights and leave only the illumination on the belly. Well,
despite it not being what we wanted, it wasn't so bad in that regard.’ (P10, OU)
Participants highly valued the sense of control, manifested through various means, including
keeping them informed and engaged during interventions, providing continuous updates on
administered medication, explaining procedures, and detailing the childbirth process. For
instance, this participant stated:
‘When they said, “we'll need vacuum extraction”, I felt the only moment of panic. My legs
were shaking uncontrollably. I vividly remember grabbing Shavonne’s [the midwife] hand
tightly and telling her, “Shavonne, I need you to explain how this will go.” She showed me
the vacuum and explained each step with detail. That's when I started calming down.’
(P5, OU)
Midwifery role on ‘childbirth essentials’ and ‘elements of value’
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The provision of close, understanding, and humanised care, particularly by midwives,
remains integral in shaping a positive birthing experience. Their presence and support,
without overshadowing the woman, her chosen companion, and the new-born, significantly
impacted the overall childbirth experience. Participant 8 exemplified this sentiment through
her description of the connection and trust with Hannah, the midwife:
‘The connection I had with Hannah [the midwife] was... well, that atmosphere... well, she,
yes, so familiar, so close... We were lucky, or not (laughs), that we got her a couple of
times [on antenatal appointments]. And then, in those two times, we established a kind of
relationship, and... and we already knew that she would be there on Monday, and since
the baby had to be born on Monday no matter what, we already knew she would be there,
and that gave me a lot of peace, you know? Knowing she would be there and knowing
that Hannah would be super sweet, and well, that treatment, like super close and as if we
had known each other all our lives.’ (P8, Combined care)
However, when instances of a lack of connection with midwives were reported, feelings of
loneliness emerged:
‘Some time has passed now, so I can talk about it more comfortably. I understand that
everyone is different, and I was at the hospital for forty-eight hours, so I saw many people
come and go, but with the midwife who came in the morning, I don't know how to call it.
Empathy? I felt a lack of presence, you know? I wasn't asking her to be by my side all the
time, but not absent either, I just felt that she wasn't as present. And that started to affect
me. [...] I felt super alone.’ (P18, combined care)
The role of advocacy for women’s empowerment
Advocacy was important for participants during childbirth, providing support even when
decisions didn't match their preferences. Women valued having someone, often a midwife,
advocate for their expectations and desires:
‘I felt that she [the midwife] had read my birth plan, understood my desires, and even
though there were decisions that I didn't truly expect, I sensed that I had some influence.
She became my voice in the team, advocating for what I wanted [...] Always striving for
that extra time and the least medicalized approach possible. She also listened to my
partner, for instance, when he conveyed, 'No, she wants it to be in the water.' Throughout
the day, she remained very attentive to both of us, always there if we needed anything,
and ensuring privacy.’ (P8, combined care)
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Women who felt more supported during childbirth described a more positive overall
experience and a sense of empowerment. Feeling empowered, listened to, and supported
during labour extended beyond the birthing process:
‘What I liked was that Hannah and Sofia [the midwives] accompanied me, and honestly, I
really liked how they intervened. The way they... They were present [..] I felt like the
protagonist, me and my baby. That was really beautiful. You feel that you are capable.
They would say, 'Yes, you can,' and I don't know... It's a very beautiful support, really. And
for me, having given birth there, well, the truth is that... I will have a very good feeling from
when I had my baby until... well, throughout my life, right? Because I think childbirth... it
marks you, right? As a woman. [...] For me it was incredible and magnificent, and I will
never forget it. For my little one, surely too, and well, for my family in general, for my
partner, and for everyone, well... Fantastic... (laughs)’ (P9, MLU)
Discussion
Our study delves into the complexities of women’s childbirth experiences within the evolving
Spanish Healthcare System, with a focus on the newly introduced MLUs. Firstly, our findings
highlight the central role of women’s expectations, deeply influenced by cultural norms,
personal experiences and societal trends. Unmet expectations pose considerable challenges
for most women25. Traditionally a communal event, changes in culture and medical practices
have shifted childbirth towards a more private affair. This transformation has altered the
visibility of real birthing experiences, introducing an element of uncertainty for expectant
mothers. Our findings are in line with Lawrence, Richardson, and Philp26 where external
sources like social media shape these expectations, often adding an additional layer of
pressure on the societal impositions that associate natural childbirth with strength,
contributing to feelings of guilt when the actual experience deviates from this expectation27.
Previous childbirth experiences profoundly impact subsequent expectations, with
dissatisfying experiences driving proactive shaping of future expectations, aligning with the
concept of redemptive birth explored by Thompson and Downe28.
Importantly, our findings reveal disparities in accessing MLUs within the Spanish healthcare
context. Uneven information presents challenges for women seeking an MLU, often relying
on information from friends or personal research29. Variations in awareness not only shape
individual childbirth perspectives but also influence expectations from the healthcare system
and place of birth choice30, raising concerns about embedded inequalities, where
expectations are inherently tied to what one can access and imagine. Comprehensive
education, positive pregnancy experiences, and diverse birthing model accessibility are
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is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted June 13, 2024. ; https://doi.org/10.1101/2024.06.13.24308819doi: medRxiv preprint
essential for targeted support, urging healthcare professionals and policymakers to address
these multifaceted influences to mitigate inequalities and vulnerabilities in maternal care.
Secondly, the model of care, as well as the role of the midwife, serve as a mediator of the
childbirth experience, acting as catalysts between expectations and the actual birthing
process, influencing the overall perception. Here once again the perception of this role is
culturally interpreted, although consensus is identified regarding the fundamental
characteristics it should encompass: respect, dignity and autonomy. Women in our study
highlight the advantages of a biopsychosocial approach characterised by
patient-centeredness, informed choice, and holistic support31. The MLUs, inherently
women-centred, align with the essential elements for a positive birthing experience outlined
by Warren et al.4. Conversely, the OU, grounded in a biomedical model, often falls short in
meeting these elements, emphasising the need for a shift towards more patient-centric
models32. Furthermore, the systematic review by Downe et al.16 also highlights giving birth to
a healthy baby in a safe environment as an important factor.
The role of midwives in delivering compassionate, understanding, and humanised care
significantly influences the overall childbirth experience, resonating with the works of
Dahlberg et al.33. Furthermore, trust and a sense of connection with the midwife during
crucial moments were highlighted as important aspects, aligning with the concept of
“watchful attendance,” proposed by de Jonge, Dahlen, and Downe34, underlying the
midwife’s role in being fully present and attentive to individual needs, though challenging to
quantify. This dynamic aligns with the concept of agency, where women perceiving control
over the childbirth process, even when it deviates from expectations, report more positive
birthing experiences35. Thus, the midwife's role inherently involves acting as a health
advocate, materialised through the preservation of the woman's agency. This is consistent
with the findings from Watson et al.36 and Kuipers et al.37. Feeling empowered, listened to,
and supported during labour extends beyond the birthing process, influencing women's
identity as mothers and their broader life perspectives 38. Our study aligns with Michels,
Kruske, and Thompson39, indicating that a positive perception of childbirth correlates with
increased self-esteem, self-efficacy, independence, and empowerment. These findings
underscore the far-reaching impact of midwifery care on women's well-being, emphasising
the need for continued efforts in fostering positive connections and support throughout the
childbirth journey.
A key finding of this study is that elements inherent to the biopsychosocial model of care are
transferable to the OU, acting as protective factors against a negative experience. Therefore,
it seems that the establishment of MLUs in the Spanish Healthcare System facilitates the
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integration of these characteristics into the biomedical model, influencing OU practices.
These findings highlight the importance of tailoring care models to individual preferences
and needs, advocating for a patient-centred approach in maternity care. The call to move
towards a more biopsychosocial model, while ensuring the safety of childbirth interventions,
aligns with the necessity for an individualised approach and a broader shift towards a
patient-centred paradigm in healthcare.
The primary strength of this study is its role as the first qualitative investigation into childbirth
experiences post-implementation of the first MLU in the Spanish Healthcare System.
However, qualitative data, although rich in narrative depth, may present challenges
regarding generalizability and replicability. Secondly, the sample’s predominantly Western
European, highly educated composition could limit the diversity of perspectives captured in
the study. Additionally, another limitation was not identifying more variables of the
socio-economic status of the participants, which could have provided a more comprehensive
understanding of the varied childbirth experiences. While online interviews offer convenience
during the postnatal period, in-person groups may be more fitting when addressing
emotionally sensitive topics. Nonetheless, efforts were made during the focus groups
discussions to foster a safe environment to encourage the expression of any type of feelings.
Despite these limitations, the study’s adoption of a constructivist paradigm and a
phenomenological approach ensures a thorough exploration of women's lived experiences.
Another strength of this study is the independent analysis of the data by researchers from
different professional backgrounds, which helps to avoid biases and enrich the interpretation
of the findings.
Conclusion
Our research provides a comprehensive understanding of the factors influencing women’s
childbirth experiences within the Spanish Healthcare System, particularly following the
introduction of MLUs. Our findings highlight the significant influence of childbirth
expectations on shaping childbirth experience, which are profoundly influenced by cultural,
social, and healthcare contexts. Disparities in information access and MLUs availability
reveal underlying inequities in childbirth decision-making, emphasising the necessity for
inclusive education and easily accessible birthing models to address vulnerabilities. The
model of care and the midwife's role emerge as pivotal mediators, influencing the overall
childbirth experience. While MLUs embody patient-centred, holistic care, the study highlights
the potential transferability of these elements to the OUs. In instances where expectations
are not met, the identification of elements from the biopsychosocial model within OUs serves
as a protective factor, fostering a positive childbirth experience. Key components such as
15
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is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted June 13, 2024. ; https://doi.org/10.1101/2024.06.13.24308819doi: medRxiv preprint
individualised attention, emotional support, respectful and compassionate care emerge as
substantial contributors to positive childbirth experiences. These insights provide valuable
information for healthcare providers and policymakers, aiming to enhance maternal care
practices and foster positive childbirth experiences through the integration of midwifery-led
care units in the Spanish Healthcare System. Further research is required to delve deeper
into the factors influencing positive birth experiences among women from diverse regions
and cultural backgrounds, facilitating more tailored and inclusive approaches to maternal
healthcare.
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