Women's satisfaction with decision-making related to augmentation of labour
Introduction
In Sweden augmentation of labour is a common intervention during childbirth. When the ‘action line’ (dilatation of the cervix at the rate of 1 cm/h) is two hour delayed, oxytocin infusion is initiated (State of the Art, 2003). In many countries intravenous infusion of synthetic oxytocin is the most widely used treatment to expedite labour when the progress is deemed to be inadequate (Enkin et al., 2000). The purpose of the intervention is to increase the level and intensity of uterine contractions and thus speed up the delivery (O’Driscoll et al., 1984; Enkin et al., 2000). In Sweden, professionally trained midwives assist pregnant women throughout the entire labour and delivery process. During normal deliveries the midwife manages the entire event, but if she observes that the contractions are ineffective, she will contact an obstetrician who, in most cases, will make the final decision about implementing oxytocin infusion. Studies about women's preference for this intervention are few and contradictory (Lavender et al., 1999; Enkin et al., 2000; Sadler et al., 2001) and how women understand the actual procedure, its effects and consequences, is not well known.
The Swedish Health and Medical Services (SOU, 1997) state that health care, if possible, should be decided upon in consultation between the client and the health-care provider. The consultation should be based on respect for the client's right of self-determination and integrity. Information to the client should be individually tailored and include the risks that accompany a medical intervention. Furthermore, if the client does not agree to a certain intervention there is an obligation to consider alternative interventions that the client may find more acceptable. It has been stressed that participation and co-operation in the medical decision-making process should be formulated in such a way that clients are not placed in a situation filled with conflicts resulting from insufficient understanding (Sahlin, 2000).
In Sweden, as in other countries, midwives are expected to not only facilitate women's choices regarding how the delivery should be managed, but also to assist women in taking some control over the birthing process (Kirkham, 1999; Lundgren and Dahlberg, 2002). This approach, generally considered to be an empowering strategy, is one way to increase labouring women's participation in decision-making (Kettunen et al., 2001). Empowerment is a useful umbrella concept also to describe the midwives’ situation with respect to professional growth and development (Kuokkanen and Leino-Kilpi, 2000). Salomonsson's (1995) study from Sweden emphasises that women's feelings and the possibility of participating in decision-making may depend on the confidence they have in the theoretical knowledge of the personnel providing their care and their perceived ability to assess the birthing process. The need for information and involvement in decision-making varies substantially among women. In fact, it has been suggested that the need for information may exceed the need for involvement in decision-making (Deber et al., 1996). Furthermore, clients may also prefer to have decisions made by or shared with physicians (Liedström Kindstrand, 1996). However, studies often show that women do not receive sufficient information about interventions during childbirth. For instance, women do not always take an active role in decision-making and midwives may overestimate the amount of knowledge women actually have of the various treatment methods (Deber et al., 1996; Liedström Kindstrand, 1996; Lundgren and Dahlberg, 2002). In a study by Sleutel (2000) the following question was raised: ‘How informed is informed consent in obstetrics?’ (p. 44).
In Sweden, childbirth education includes discussions about how to prepare for the birthing process, which has shown to have an effect on how women think about their forthcoming delivery, how they envisage the length of labour and how much control they think they will have over the birthing process (Rydén, 1997). The length of labour has been described as one of the most important aspects of the childbirth experience for women. In an interview study about women's perceptions of childbirth and childbirth education, the actual duration of labour and women's perception of the length of labour was found to be an important theme (Hallgren et al., 1995). This time aspect seems to be a more important issue later in pregnancy as the time of birth approaches (Rydén, 1997).
Our clinical experience is that the rates of augmentation of labour in Sweden have increased in recent years, following the introduction of the ‘Dublin method’ (O’Driscoll et al., 1984). However, very little is known about labouring women's experience of participating in the decision-making process leading to this intervention. Thus, the objective of the present study was to describe some women's experiences of their participation in decision-making related to the augmentation of labour.
Section snippets
Approach
In this study a modified grounded theory approach was used to better understand women's experiences of participating in decision-making related to augmentation of labour. Grounded theory is a qualitative research method that offers a systematic approach that assists illumination of varied responses and generates theory about particular phenomena. Data collection, analysis and theory stand in a reciprocal relationship with each other and issues relevant to the study area are enabled to emerge (
Findings
The 20 participants in the study were 22–40 years old with an average of 31 years. All women were primiparae and had had a vaginal delivery. The length of the labour and delivery ranged from 8 to 25 h, with a mean time of 17.1 h. All women spoke fluent Swedish although some were from an immigrant background.
Analyses of data revealed that there were eight related categories concerning women's experience of decision-making in relation to augmentation of labour.
These eight categories and how they
Discussion
The most decisive element for explaining how women experienced being involved in decision making related to augmentation of labour was the support and guidance given by midwives. This is in accordance with the findings in a study by Tumblin and Simkin (2001) about nulliparous women's expectations regarding nurses activities in labour. In that study supportive care activities, from the nurses, were more important issues than the clinical-care activities.
The open-ended interview method was chosen
Conclusion and implications
The findings of this study reveal that information and empowering are far more important for women than to participate in decision-making regarding augmentation of labour. The women were satisfied with decisions made when they also experienced good support and guidance from midwives and they had confidence in the midwives’ assessments. Thus, the findings of our study could be valid for some other cases of decision-making depending on women's knowledge and expectations about that particular area
Acknowledgements
We would like to thank all the women who participated in this study. We are grateful to Karolinska Institutet, Stockholm, Sweden for the grants that contributed to the possibility to conduct this study.
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