*Melinda Rados1, Eszter Kovács2, Judit Mèszáros3
Intimacy and privacy during childbirth. a pilot-study testing a new self-developed questionnaire: the childbirth intimacy and privacy scale (CIPS)
1Department of Applied Psychology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary
Head of Faculty: prof. Zoltán Zsolt Nagy, PhD
2Health Services Management Training Centre, Semmelweis University, Budapest, Hungary
Director of the Centre: Miklós Szócska, PhD
3Faculty of Health Sciences, Semmelweis University, Budapest, Hungary
Head of Faculty: prof. Zoltán Zsolt Nagy, PhD
Introduction. Based on the findings of academic literature, evidence has found that physical and social environment play an inherent role in the birthing procedure. Birth is a natural process, with a specific sequence of hormonal changes and communication between mother and baby. Environmental stress, through a surge of adrenaline, can hinder the unfolding of the special physiological responses, and as a consequence of the contractions becoming less strong and frequent, the birthing process can stop. For this reason, privacy and intimacy are of special importance around the labouring mother.
Aim. The aim of our study was to explore what role privacy and intimacy play during labour and delivery. Furthermore, we aimed to discover whether perceived stress is related to privacy and intimacy experienced by mothers.
Material and methods. The newly created Childbirth Intimacy and Privacy Scale (CIPS) is introduced to measure physical and social privacy, safety and some other features which proved to be important during the birthing process keeping it on the physiological level. Additionally, we assessed stress experienced during birth with the shortened version of the Perceived Stress Scale (PSS).
Results. PSS and CIPS measures showed satisfactory internal consistency, data came from a normal distribution and items were strongly intercorrelated. Significant differences were found in PSS regarding education, marital status and socio-economic status (SES). Mothers with single marital status and low SES reported significantly higher perceived stress. Out of all CIPS items, mothers indicated high levels of privacy in features regarding no photos being taken, continuity of care throughout labour and delivery, patience and security provided by birth attendants and a lack of embarrassment in their presence. No significant differences were found when testing the mean value of the total score by using ANOVA; however, intimacy and privacy seemed to be slightly higher among mothers over 30 years old, having at least a third child, married, with lower qualifications and higher SES.
Conclusions. CIPS has proven to be an adequate measuring tool for assessing intimacy and privacy experienced by mothers during the birthing procedure. When privacy was rated high on the scale mothers perceived less stress and when rated low they experienced higher levels of stress. Therefore, if mother-focused care is the goal, caregivers should create and foster an atmosphere where intimacy and privacy are present, making a more satisfying birth possible with less interventions needed.
At the turn of the millennium, new methods were introduced in technology to minimise the risks of complicated pregnancy and birth, which alleviated the pains and troubles of the mothers and of their babies. At the same time, we can witness the use of technology in uncomplicated births as well. This means that induction of labour, continuous electronic monitoring, the use of synthetic oxytocin, routine application of intravenous lines and epidurals are becoming the norm. But what does normal birth mean in this biomedical era of maternal care? Many researchers have attempted to find out what normal birth is. Previous research usually refers to this with the term ‘normal labour and delivery’ where birth is seen as a natural and physiological process, without the use of interventions (1).
There is evidence that interventions increase both maternal and fetal distress (2). Although around two-thirds of women state they would like to have a natural birth (3), most women have lost their confidence in their bodies to be able to give birth without any technological intervention (4).
It is of importance to clear what the physiology of natural birth is. In the process of labour and delivery the hormones play an indispensable role. First we need to point out that there are two hormones which have contradictory functions in this process. Oxytocin is the hormone naturally released in the body of women during birth which controls the contractions of the uterus, among other processes. A special catecholamine, adrenaline, is the hormone secreted when the organism faces stress. The theory of ‘fight or flight’ states that facing threat one has two options: fight the enemy or run away (5). Compared with the previously mentioned ‘fight or flight’ response, the theory of the ‘fear cascade’ adds that there is an unconscious, automatic hormonal response to acutely stressful events (6). In the process of birth adrenaline has two functions. On one hand, to disrupt the production of oxytocin during labour, which in other species is an adaptive response in the face of threat. As a consequence, labour slows down or stops until the mother moves to a safer, more protected place. On the other hand, the vasoconstrictive effect of adrenaline diverts blood away from the abdomen, which causes less blood available for the placenta and fetal oxygenation. This usually leads to fetal distress. In other words, whenever women feel uncomfortable or stressed during their labour and delivery, stress occurring in their environment can lead to slowing down the birthing process (4). Slow labour and fetal distress are the two main indications for intervention in childbirth once labour has begun.
The sources of environmental stress can be physical or social. If there are disturbances in the physical environment, it can either arise due to changes in the birth environment (e.g., change of birthing room while labouring), or due to the inappropriate physical surroundings, which in both cases might cause distress. The social environmental stress might appear as a result of a lack of privacy, reassurance and comfort provided by the caregivers.
From a psychological point of view stress, regardless of how long it is experienced or how intensely it is felt, is associated with the likelihood of developing certain physical or psychological disorders (7). It plays an important role in how predictable, controllable the encountered stress is, and what resources one has to cope well with it. It is relevant to point out that this is a complex process, where the personal characteristics and the psychosocial environment the person is situated in are all interacting. Knowing what an essential experience giving birth is in a women’s life, it is going to have a substantial influence on her later well-being, her mother-role, her connection with the newborn child, and whether she develops a disorder of any kind. Here the role of a professional caregiver is to provide support calmly and confidently for the mother in order to make her capable of mobilizing her resources to cope with the pain of the contractions, and to resign herself to the unexpected.
Another array of theory comes from Odent, who has come to his findings through his work as an obstetrician for several decade-long work. The birthing process is regulated by evolutionarily ancient brain areas, where hypophysis and hypothalamus are responsible for the secretion of various hormones (8). According to his views, mothers during labour have to reach a special birth state, sometimes even called an altered state of consciousness, to let these brain structures take their lead. If inhibition arises during birth it usually comes from the cortex. The stimulation of the neocortex, the centre of intellect, is a hazard in case of natural labour. When the mother is stimulated intellectually, or feeling watched, the neocortex is always active. Odent concludes, that because of the previously mentioned processes, it is inadvisable to engage in discussion with the labouring woman, because language is controlled by neocortex. Strong lights, the beeping and buzzing sounds of machines (e.g., continuous fetal monitoring) and the feeling of being observed should be avoided as well, because these all create alertness in mothers and they are not able to focus inward. He stresses that a good caregiver is like a mother-figure, where intimacy is present so women do not need to be embarrassed and feel free to do whatever they like. If this is neglected birth tensions and complications may occur and lead to unnecessary complications and interventions. This lies in the hands of professional caregivers providing maternity care. On the other hand, physical environment through various neurobiological mechanisms plays a role as well, in the way midwives care for women during childbirth. Birth unit design evokes a neurobiological response not only in women but in the team attending to them as well, which is going to have a cumulative effect on mothers during this special experience of giving birth (9). A positive work environment triggers oxytocin release in the person acting in it. An important but lesser-known effect of oxytocyn is its prominent role in social interactions, in connecting people under calm circumstances (8, 9). Consequently, oxytocin helps in providing emotionally sensitive care for the birthing mother from the midwife and others in the team.
What are privacy and intimacy and why are they important during birth?
Research regarding privacy in the field of midwifery is unfortunately rather limited, mostly preoccupied with confidentiality and privacy rights (10). Leino-Kilpi et al. refer to four kinds of privacy: informational, physical, social and psychological. In their study they compared five countries in the first three dimensions (11).
Physical privacy might be the most obvious of all. During the last decades there has been a visible change in the arrangement of birthing rooms in many hospitals of Budapest. There has been a shift from multiple-occupancy birthing rooms to mainly single-occupancy birthing rooms. This has probably led to higher levels of privacy perceived during childbirth. Because of the intimate nature of acts taking place in a birthing room, respecting this is of great importance. These acts include undressing, gynaecological examinations, body or perineal massage and, of course, the birthing process itself. The above-mentioned comparative study investigated physical privacy on post-natal wards. It reveals that ensuring that showering, toileting and having enemas take place secluded from other mothers is strongly required (11). A study carried out in the United Kingdom suggests, that although women reported to be content with the sensitivity, support and frequency vaginal examinations were conducted with during labour, there are still some aspects to be improved. These are: pain and distress accompanying vaginal examinations and a lack of information why the examination is necessary. Two-fifth of women felt that even if they had wished, they would not have had the opportunity to refuse the examinations (12).
Aspects of social privacy include the mother’s capacity to control her social contacts. Its examples are: controlling who comes into the room, how many people there are in order to avoid overcrowding and engaging in discussions only to the limit that is convenient for the mother. The ‘knocking before entering’ policy should be applied by all caregivers around the mother to prevent distraction or unnecessary stress. A study conducted in Norway among women given birth at home has shown that ‘not disturbing’ appeared to be the most influential factor during care. She could be disturbed by every person present at the labour progress, be it the midwife, the partner or any member of the supporting team. Protecting the mother from disturbance was the main task to be carried out by the midwives (13). In hospitals, despite the evident dominance of the medicalised protocols of the obstetric-led unit, a private, intimate place needs to be created, where women can feel safe during labour and delivery. They need a place, where they feel unembarrassed to do whatever they wish, such as vocalising, moving around freely, taking a birthing position of their own choice, etc. The possibility of being able to be alone intimately with the newborn (and the father) right after delivery, in a way that the baby is not separated from the mother to be cleaned and dressed, creates a satisfying experience. Both of the afore-mentioned procedures with other routine check-ups can take place a short while later. Odent points out that this intimacy with the baby right after birth, is a significant event allowing the natural oxytocin to be secreted, which enables the placenta to be delivered without any further invasive techniques (8). This closeness and togetherness of the mother and the newborn can form the early building blocks for the later attachment ideally developing between the two of them. The dimension of social privacy is the one mostly matching the concept of intimacy, as it is defined as closeness and belonging to another person. The same trusting relationship between mother and caregiver is inevitable for appropriate care in the birthing room.
The dimension of informational privacy has been studied most widely (10). This covers the topics of the right to informational privacy, where the information given by or to a patient needs to be kept strictly confidential by hospital staff. This might mean not needing to talk in front of other mothers about personal and medication issues. A common custom in many hospitals, with the aim of raising patients’ satisfaction with their privacy, is to place curtains around beds in multi-occupancy hospital rooms. A qualitative study in New Zealand pointed out that curtains in shared hospital rooms are able to provide only visual privacy but fail to provide auditory privacy (14). In this manner, informational privacy is compromised because discussions between patients and professionals may be overheard, hindering patients to share personal information about any aspect of their health.
The last dimension of psychological privacy is the least studied dimension, probably due to its perception as the subjective side of all the above dimensions. They might best be understood through regarding the individual’s personal history. All birth experiences reminding the subject of any earlier personal life event gain personal meaning and can evoke emotional and psychological responses of various kinds. Lothian states that all women need an environment where they feel protected not only medically, but in a way that also provides them emotional privacy and safety to promote physiological birth (2). A study conducted in Scotland revealed that despite there being a number of alternative ways to measure labour progress, vaginal examination is the most commonly applied method (15). It is used routinely, without seeing it as an intervention. It has been observed that most women find these unpleasant, embarrassing and painful. The way women come to terms with this is clearly a subject of psychology.
Singh and Newburn pointed out in their article about mothers’ priorities of the birth environment that women in the first place wanted a clean room, secondly, being able to stay in the same room throughout labour and delivery and, thirdly, having the opportunity to mobilise and walk around (16). A review has recently been written about the effects of physical activity during first stage labour on its length (17). In most cases they have found no change regarding the length of second stage labour with women being physically active while labouring, compared to another group of women labouring in a semi-recumbent position. A second set of articles has found a shortening of first stage labour due to physical activity. Although it is not clear whether there are differences on the outcome, it is important to note that none of the articles mentioned an increase in the length of second stage labour as a consequence of walking or moving during labour. The authors point out that there were no systematic ways as to how special features of physical activity and moving have been measured and recorded, thus it might be required to make even more detailed studies on the topic. It is well documented that women who are involved in the decision-making process and are free to take birthing positions of their own choice are more satisfied with the outcome and feel more empowerment during birth (18, 19).
Nowadays, if mother-focused care is the goal, in order to increase mothers’ satisfaction, these features and possibilities should definitely be provided. At the same time, further investigation needs to be made as to how to facilitate natural birth, keep interventions at a minimum to help the mothers and their babies to have a favourable experience of birth. Keeping this in mind, it might even have another beneficial side-effect: saving hospital and healthcare costs.
Our research aim was to gain insight into what role privacy and intimacy play when women go through a very special time of their lives: namely, becoming mothers. Besides that, it is essential to find out what birth attendants can do to construct and maintain an environment fostering privacy and intimacy. The essential objective for creating a new scale was to measure relevant aspects of privacy and intimacy during labour and delivery.
MATERIAL AND METHODS
The questionnaire for our investigation consisted of three main parts. The first set of questions inquired about age, marital status, number of births, a question regarding the educational level and another about socioeconomic status compared against the Hungarian average.
Next, the questionnaire included a shorter version of the Perceived Stress Scale (PSS), the most commonly used scale to measure the perception of stress. It not only measures what type of objective stress the individual went through, but aims to capture how controllable or predictable it was perceived and how overloaded one feels. The classic PSS asks how the subject felt over the last month’s period. In accordance with methodological and statistical advice, we have made a change in the time span making it appropriate to measure the stress felt during the birthing procedure, therefore, our questions were formulated „during the birthing process”, instead of „in the last month” (e.g., „During the birthing process, how often have you felt confident about your ability to handle the arising problems?” and „During the birthing process, how often have you felt that things were going your way?”). We have used a validated short version (four questions) of the classic scale (7). The informants are requested to tell, with the help of a 5-point Likert scale, where ‘0’ means never and ‘4’ means very often, how often they have felt a certain way.
The Childbirth Intimacy and Privacy Scale (CIPS) is a self-made survey incorporating the main aspects of physical and social privacy combined with intimacy issues according to the existing literature previously mentioned. It consists of 21 statements. The participants are asked to indicate their answers on a 5-point Likert scale, where ‘0’ means the specific feature totally absent, and ‘4’ entirely present at the birthing process. The first few questions gather information on the aspects of physical privacy (e.g., „The door was closed” and „One could see into the birthing room through the door or a window”). Another set of questions assesses the freedom to act any way the mother feels and letting go of how she ‘should’ behave under these circumstances (e.g., „During the birthing process I was able to move around freely” and „During contractions I could sigh or scream freely”). That is followed by a series of questions about social privacy (e.g., „The birth attendants were the same during the entire birthing process” and „Other unfamiliar people (other doctor, midwife, student practitioner) disturbed my labour unexpectedly”). Other dimensions based on literature are: feelings of being observed, safety, hygiene, touching, patience with the mother (8, 13, 16) (Odent, Blix, Singh and Newburn). The scale was reviewed and discussed with two experienced midwives, who gave ideas in order for the questions to truly match the present maternity care protocol of childbirth in Hungary. Their notions and feedbacks were included when constructing the final version of the scale. For pretesting the questionnaire two new mothers were selected and the tests were completed in under 6 minutes.
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