Twenty papers were included in this integrative review, six research articles and 14 anecdotal articles. The six research articles were studies conducted in either Australia or the United Kingdom. Two studies used a qualitative approach (25, 28), and four a quantitative methodology (29–32). All 14 anecdotal papers were published in the UK in professional midwifery journals.
Four overarching themes were identified: ‘Insider knowledge plays a role in decision making’, ‘Navigating the childbirth journey’, ‘Impact of care on the birth experience’, “From midwife to mother’ (see Fig. 2).
Theme 1: Insider knowledge plays a role in decision making
This theme included four subthemes: ‘choosing a mode of birth’; ‘choosing a carer’; ‘choosing a model of care’; and ‘choosing to birth at home’.
It was apparent from this review that midwives were aware that they possess unique knowledge about obstetric risks, and various medical conditions and complications that could occur, when compared to women in general (28, 29, 32–36). This ‘insider knowledge’ played a key role in their decision making and was used to actively make decisions that would allow them to be in control of their care (28, 35, 37–40). Midwives made choices to achieve control over external factors, such as the birthing environment, who their maternity care provider was, and the type of interventions they would allow (33, 35, 36, 39–43). Being in control was particularly important for midwives who had non-conventional birth plans (35, 37, 40, 44).
Choosing a mode of birth
For the majority of midwives in this review there was a clear preference for a ‘normal’ vaginal birth with minimal interventions (28, 33, 35–45). Church (28) identified that a vaginal birth was perceived as providing a sense of control over the birth experience. A normal birth was considered by midwives as a “state of being in control”; a state “in which the mother assumes some physiological power over the birth” (28 p234). For some midwives in the literature, their professional experience of witnessing “awful normal deliveries” (28 p233) led them to choose an elective caesarean (28, 34). Again, Church’s study identified that this was related to control over preventing potential negative outcomes or complications associated with a normal vaginal birth (28).
Choosing a carer
The review identified that insider knowledge also influenced their choice of carer. There were two factors involved in the midwives’ choice of carers: sharing a similar midwifery philosophy with their carer (33, 40, 44) and needing to trust their carer (33–36, 38–42).
Sharing similar philosophy and beliefs
Having similar birthing beliefs and philosophy to their carer was important to midwives’ when choosing their caregivers (36, 40, 44). As one midwife described “I had found the person with whom I almost perfectly shared a philosophy and practice style…”(40 p26). Another midwife looked for midwife carers who would be comfortable in supporting her wish to have a vaginal birth after caesarean (VBAC) at home (44). For another midwife her choice of obstetrician was based on choosing one that would not argue with her idea of a homebirth (33).
The need to trust their carer
Trust was an important element of support, and achieving a trusting relationship between themselves and their carer appeared to be crucial (36, 38–40). A number of midwives talked about intentionally seeking out carers whom they felt they could develop trust with (36, 38–40). For some midwives this meant having midwife friends and or colleagues with whom they already had a trusting relationship, to be present with and support them during labour, (33–35, 39, 41, 42). Good support was important to achieving the type of birth the midwives wanted (34–36, 38, 39) “I enlisted two close friends who I knew would be effective birth supports and looked forward to a vaginal birth” (34 p48).
Choosing the model of care
A number of midwives in the literature preferred to be cared for under midwifery continuity of care models (33–35, 39, 41, 42). They sought out care options as soon as possible to ensure they got care from a midwife they knew and trusted (36).
Choosing to birth at home
In a number of papers, the midwives discussed wanting to have a home birth (28, 33, 35–44). For several midwives this choice was because they believed giving birth at home provided them with a sense of control and autonomy over their birth experiences (33, 35, 36, 38, 41, 43, 44).
Having insider knowledge as a midwife gave midwives knowledge about homebirths including knowing that at home, they would be free to labour how they wanted, with privacy and without unnecessary hospital interventions (28, 35–37). For some midwives their professional experiences of childbirth in hospitals, as well as their involvement in obstetric emergencies, led to a perception of a higher chance of these emergencies occurring in hospital (33) and thus there was a perception that they would experience a greater loss of control birthing in the hospital setting (33, 35, 36).
Theme 2: Navigating the childbearing journey
The theme ‘Navigating the childbearing journey’ included three subthemes: ‘taking advantage of insider knowledge to achieve agency’; ‘difficulty achieving agency’; and ‘managing the midwife brain – the internal dialogue’.
Taking advantage of insider knowledge to achieve agency
Insider knowledge not only influenced midwives’ decision-making; it was also used to navigate the maternity care system. Midwives described drawing on their professional knowledge and professional status at times, to challenge the system and those working within it, to achieve their birth goals (28, 33, 34, 41). As such, insider knowledge was seen by some as providing midwives with an advantage in achieving what they wanted and gaining control and support for their decisions during the birth (33, 34, 39). In the postnatal period, insider knowledge of breastfeeding, and professional experience supporting women, was seen as an advantage in navigating their own breastfeeding journey. In McMulkin and Malone’s (32) descriptive cross sectional study of 210 midwives’ personal experience of breastfeeding, 66% felt that the theory they learned about breastfeeding was applicable to practice, and of these 76% felt that this theory was applicable to their personal experience of breastfeeding. For the midwives in this study (32) their experience helping mothers learn to breastfeed played a positive role in their own ability to breastfeed.
Difficulty Achieving Agency
While some midwives described how their professional standing as a midwife was used to successfully negotiate care, not all midwives were treated as knowledgeable decision makers, with some experiencing difficulty in achieving agency (28, 32, 41). Despite having professional midwifery knowledge, some midwives described how their ability to be actively involved in the decision-making surrounding their care was difficult (28, 41). For these midwives, maternity care providers assumed greater control over their births, and this was particularly evident in the midwives who birthed in hospital (28, 32).
Managing the midwife brain – the internal dialogue
While midwifery knowledge gave some midwives agency, insider knowledge and experience was a double-edged sword. Midwives experienced a constant internal dialogue during their pregnancy between their midwife brain and the childbearing woman’s brain (33, 35, 40–42). This internal dialogue had both positive and negative consequences. For some it provided reassurance but for others it created anxiety.
The midwife brain creates fear and anxiety because of what they know
For some midwives the internal dialogue appeared to be driven by their knowledge of potential complications and negative outcomes. This meant they were on the lookout for things that could go wrong (28, 33, 35, 42) and this contributed to fear, stress and anxiety (28, 33, 34, 39, 40). For example, one midwife described experiencing feelings of fear during labour, that her pelvis was not large enough to let the baby through (39), and another expressed a fear of haemorrhage (because of fibroids) if she gave birth at home (28). For other midwives’ their experience of caring for mothers who had had inductions caused anxiety around the potential need for intervention for their own labours (28, 34, 38).
The midwife brain creates tension between a pregnant woman’s brain and the midwife’s brain
For some midwives, the internal dialogue caused by having insider knowledge caused tension between a pregnant woman’s brain and the midwife’s brain. Constable (33) described this as an internal argument within her own brain:
“At 17 weeks I had a small post-coital bleed and this was the first time I really discovered the internal argument between the midwife part of my brain and the paranoid pregnant woman side” (33 p15).
In Constable’s description, the midwife brain would present logical reasons for a haemorrhage, while the pregnant woman’s voice would say "but what if…"(33 p15). Jennings (42) described herself as the “anxious pregnant midwife” (42 p19) relating a discussion with her husband about whether to go to hospital to have a cardiotocograph, despite recognising that as a midwife she would not recommend this to a woman in the same situation (42). This internal argument could cause conflict for midwives, who were caught between their midwifery knowledge of things that could happen and their instincts to just labour and birth (28, 33, 35, 42).
‘As my birth approached, I was caught between my knowledge of all the things that can happen, my belief that attended birth is safer and my instinct to crawl into a hole and have my baby without anyone around” (40 p26).
This conflict was seen as negative for some to a point where one midwife wished she didn’t have insider knowledge
“…when I had that bleed …. that was the one time when I thought ‘oh gosh, I wish I didn’t know what I know, because I think I could, you know, imagine all the problems that were going on with that bleed’….” (28 p233).
Comparing her pregnancies, Constable (33) described her pregnancy after becoming a midwife, as being more anxiety driven and needing the psychological reassurance of listening to the heartbeat.
The midwife brain creates reassurance
Although insider knowledge could cause a negative internal dialogue between the pregnant woman and pregnant midwife, insider knowledge was also seen by some midwives as positive. For these midwives their professional knowledge was reassuring because they knew the most likely cause of small problems that arose (25, 28, 29, 33, 35). For others, their knowledge helped to prepare them for possible outcomes, providing insight to accept situations when obstetric risks outweighed the possibility of a safe normal birth (25, 28). There were also elements of their care, such as vaginal examinations, that they were able to perform on themselves because of their midwifery skills. For example, several midwives examined themselves vaginally to determine their own progress in labour (35, 42–44).
Midwives also used their professional knowledge and experience to reassure themselves in the postnatal period. In a study of midwives’ knowledge and attitudes towards breastfeeding, despite a large number of midwives reported experiencing problems with breastfeeding, these were not necessarily perceived as unresolvable, but rather viewed as part of the process that with persistence could be overcome (29).
Theme 3: Impact of care on the birth experience
The theme ‘Impact of care on the birth experience’ included two subthemes. These were: ‘positive relationships lead to positive experiences’ and ‘disrespectful care may lead to birth trauma’. In the literature, midwives described various experiences of care.
Positive relationships lead to positive birth experiences
Midwives reported that when they achieved trusting and respectful relationships with their maternity carers, they viewed these in a positive way. They described their maternity carers as being fully focused on them (36), made to feel special (38) and “cocooned” in love (44 p60).
Having a positive relationship with their maternity caregiver appeared to be equally important regardless of where the midwife gave birth. The majority of midwives who had homebirths reported positive relationships with their caregivers, were satisfied with the care they received, and reported an overall positive birth experience (33–39, 42–44). Midwives who gave birth in hospital and who reported a positive relationship with their maternity caregivers, also reported an overall positive birth experience (34, 45, 46).
Those who described positive relationships with their carer described trust as being crucial to their relationship. In the literature, trust was expressed in two ways: the carers’ trust in the childbearing midwives’ ability to give birth, and the childbearing midwives’ trust in their carers commitment to honour and respect their wishes. Midwives expressed the need to have a mutual trust so that they could feel relaxed and comfortable (36, 38–40). They felt that caregivers who trusted in their ability as a woman to birth their baby, was important to them to be able to trust in their own ability to give birth (36, 38, 39).
“When I lost faith during transition I needed, as an anchor, Sarah's quietly expressed belief in my body and the birth process: she held my belief for me when I could not” (39 p25).
Trust was important for midwives during childbirth (34, 36, 38–40). Having trust in their carers meant the midwives were reassured that their caregivers would not intervene inappropriately, therefore providing them with a sense of control (39). Consent appeared integral to trust, with midwives stating that nothing was done to them during labour without consent (34) and everything was consented to, including vaginal examinations (36). Achieving a trusting relationship with their carers also meant they were able to ‘let go’ of their midwife brain during the birthing process and let their body do what it needed to do to give birth (34–36, 39, 42, 43). One midwife described this letting go as being able to “slip out of the neo-cortical activity of the intellect that Odent writes about and into another consciousness” (39 p24). Letting go was also described as “that hormonal fog of active labour” (42 p20) and “disengaging the mind” (35 p14) which allowed the body to take over and push their baby out.
Midwives who achieved trusting and respectful relationships with their caregivers described giving birth as being an empowering (35, 37) and powerful experience (38–40, 43). Their birth gave them confidence (35, 36) and a great sense of achievement (39, 46) at being stretched to their limit and finding out they are more than what they thought, providing a sense of completeness about the birth experience (36). Others described the experience as being awesome (39), fulfilling (37), exhilarating (42), and an “explosion of fireworks” (45 p62). One midwife described her experience as a reminder that the body is truly awesome and intrinsically designed to birth (35).
Disrespectful care may lead to birth trauma
Conversely, not all midwives described a positive experience with their care provider. Some described feeling dismissed by their care providers, vulnerable, in need of more support, and or receiving indifferent care. Feeling dismissed by caregivers was often within the context of the lack of a mutual trusting relationship. While this was mostly reported within the hospital setting, Burlow (41) described her request for a homebirth as being faced with opposition from the community midwives who were based in the hospital, ultimately leaving her feeling “trapped” and “powerless” (41 p18).
This review identified that for most of the midwives who birthed in the hospital setting, fears and anxieties, heightened by their increased professional knowledge were often unaddressed by caregivers, even at times having their valid concerns disregarded and dismissed (25, 28, 38). These midwives were left feeling alone (28, 32, 40), unsupported in their worries (28, 32, 38) and with the feeling that their professional knowledge was unacknowledged (28). Midwives were also anxious about possible negative outcomes for their babies. This was exemplified in one midwife’s story of being dismissed by her caregivers when she presented with premature rupture of membranes, only to find it confirmed by a scan weeks later. Her fear and anxiety during this time was not addressed by maternity caregivers, which left her feeling “cross,” (28 p233) dismissed, and anxious about the possible negative outcomes to her baby (28).
When it came to breastfeeding, midwives mostly reported being left to their own devices with little support from their care providers. Studies found that being unsupported in breastfeeding was due to their professional status as midwives (32, 38, 42). McMulkin and Malone’s (32) study on breastfeeding support reported that the midwives were “… respected by the staff as professionals who didn’t require any assistance or support” (32 p12) with breastfeeding and the care of their new baby (32). This approach to breastfeeding support could also be considered dismissive, because some midwives in their study described feeling ‘helpless’ (32 p12) when confronted with their own baby, and stated that they would have appreciated more support than they received in the early stages of breastfeeding their baby’s (32).
While some midwives reported a lack of adequate support, another midwife described receiving an indifferent approach to care (38). This midwife described feeling like she was on a conveyor belt and that “we were simply 'going through the motions'” (38 p25). She met the midwife only on arrival to hospital and never felt completely relaxed and safe during her transitional stage. She described not feeling encouraged or supported:
“I never felt completely relaxed or safe, and during the transitional stage, rather than feeling encouraged and supported, supported in feeling the overwhelming emotions which overtook me, I felt that I must do as I was told and not ‘lose control’” (38 p25).
The effect of this was that she had “no memory of euphoria, no warm words of congratulation between us and our midwife, simply paperwork, a goodbye and a shift change!” (38 p25).
Ultimately, midwives who received respectful care and developed a trusting relationship with their care provider often reported overall positive birth experiences (34–39, 42–46), whereas those who were not treated with respect felt their birthing experiences were negative or traumatic (25, 28, 31, 32, 38, 41).
The impact of birth trauma
A number of midwives reported feeling traumatised by their experience of childbirth (25, 30, 31, 40, 41, 44, 47). These midwives described having flashbacks, nightmares and panic attacks for years (44). In the study by Toohill, et al. (31) 41.6% (97) of participants indicated they experienced trauma during their labour and birth. Having interventions was the main cause of trauma, and receiving maternity care which was described as ‘assaulted’, ‘aggressive’, ‘demeaning’, ‘intimidation’ and ‘bullying’ (31 p67) were also key reasons given for birth trauma. In another study, more than one-fifth of midwives (22.%) reported a traumatic experience when giving birth themselves (30) and this (OR = 1.76, 95% CI [1.09, 2.83]) was associated with an approximately twofold increase in risk for probable PTSD. Having a traumatic birth experience was also associated with Postnatal Depression (PND) (25). Of the 22 participants in the study by Redwood (25), six were diagnosed with PND and three exhibited symptoms of PND during the interviews.
Depression was also reported by midwives in a number of other studies (25, 31, 46). Being separated from their baby was seen as contributing to developing depression (31) and this was closely tied to difficulties with bonding with their baby (25, 31, 46).
Theme 4: From midwife to mother
The theme ‘From midwife to mother’ included two sub-themes: ‘unprepared for childbirth and motherhood’ and ‘transitioning to motherhood’.
Unprepared for childbirth and motherhood
In several of the studies midwives expressed that their professional knowledge and experience did little to prepare them for childbirth and motherhood despite their expectations that it would (25, 40, 46). For one midwife who’s birth had not gone according to plan, she declared “never in a thousand years would I have anticipated this happening to me” (41 p18).
Despite caring for labouring women on a regular basis, many midwives described the shock of labour pain (25, 36, 39, 40), and used words such as “horrendous” (36 p4) “bone-crushing”, “overwhelming”, “unbearable”, “exquisite pain” (40 p26) that was “so terrible and so frightening” (39 p23).
For some midwives, the pain was “horrendous” and “shocked” beyond all expectations (36 p5) with some left wondering why no one had told them about how painful it would be (25, 39). Lee-Ribas (40) had “no idea” of the “bone crushing, unbearable, overwhelming” and “exquisite pain” of “back labour” (40 p26) but her realisation that she hated giving birth and having the “veil of illusion about birth” (40 p27) being torn away was as painful as the physical labour. Her experience of birth, left her questioning how she could have supported so many women without realising what they were going through.
“How could I, how could I have stood beside those women, so many of them, calmly breathing, murmuring ‘you can do it. You are doing it,’” “Letting them trust me. I knew nothing. I did not deserve their trust” (40 p27).
Hinsliff (34), although able to understand the reasons for the procedures she had during labour, described labour as a “terrifying experience” (34 p48) from the second stage onwards.
In addition to not being prepared for the reality of labour, midwives also experienced a conflict between their professional knowledge and their personal experience of breastfeeding. Tennant (46) described having a very difficult and unexpected breastfeeding experience and felt that her midwifery training did not prepare her for motherhood, despite her expectations to the contrary.
“My experience as a midwife did very little to prepare me for motherhood. Did I expect it to? Well, yes, on reflection I thought it would. The first day at home with my son James made me realise how mistaken I had been!” (46 p438).
Transitioning to motherhood
The quality of their birth experience and transition to motherhood appeared to be dependent on their perceived level of control during childbirth. Control was largely contingent on the level of effective communication and trust experienced between themselves and their maternity care providers (25, 36, 38, 39). In Redwood’s (25) study, even when birth did not go to plan, participants who felt they were in control of their birth experience, and perceived that communication with their maternity care provider was good, had a better transition to motherhood than those who didn’t (25).