The Lived Experiences of Postpartum Women in Ghana Regarding Nursing Care During Childbirth and their Concept of Care-A Phenomenological Study

Background : Studies have confirmed that the nurse during the period of delivery would be the deciding factor whether the woman would have a positive or negative birth experience. This positive or negative experience depends on the quality of nursing during this period. Hence it is important to know the concept of care from the perspective of postpartum women and their lived experience of nursing care during the period of childbirth. This is because patients’ satisfactory of services rendered is a yardstick for measuring quality of care. However, there is no literature on the lived experience of postpartum women regarding the nursing care rendered to them during childbirth and the viewpoint of postpartum women on the concept of

ISSN: 2581-7493 women regarding their concept of care.The concepts of emotional, physical and informational support, pampering and nice communication and cordial relationship should be taking into consideration when nursing them.This will lead to taking care of them according to their preferences, wishes, needs and values which will lead to their satisfaction and hence quality of care since quality of care is determined by patient's satisfaction.This will also lead to targeted, individualized, patient centered care for these women.
Background: Childbirth experience for women has immediate as well as long-term positive or negative physical and psychological effects on their life, well-being, and health [1].Both positive and negative experiences can affect the transition to motherhood.Negative birth experience can be a traumatic experience and increases the risk of negative health outcomes, such as postpartum depression [1,2].Studies have confirmed that nurses have an important role during the period of delivery on women's experiences [3].One way of minimizing maternal and neonatal mortality in developing countries is to entreat women to give birth in health facilities with the help of skilled birth attendance such as midwives, doctors, or nurses who have had the requisite training to manage uncomplicated pregnancy, childbirth, and immediate postnatal period and in the identification, management and referral of complicated cases [4,5].Despite the known medical advantages to delivering in a facility with a skilled birth attendant, many women still do not seek such care [5].The reported abuses by midwives and also the differences in perception and opinion of the concept of care by health staff and women in labor are the causes of this problem and hence to solve this problem of women not seeking labor and delivery care in the health facility, there is the compelling and urgent need for the concept of care from the viewpoint of the woman in labor to be researched into.
In the past, the yardstick for measuring quality medical services was dependent on evaluating the objective outcomes of patients' physical condition.However, for now researchers have started considering patients' satisfaction as a yardstick for evaluating the efficacy and standard of medical care [6].Respecting the wishes, and needs of patients is foremost to every humane health care system [7].
Approximately 99% (302000) of the World's maternal deaths in 2015, was from poor nations, with sub-Saharan Africa roughly accounting for 66% (201 000) of maternal deaths [8].Approximately one-half to two-thirds of maternal deaths occur within one day of labor and delivery [9,10].In the world, approximately half of the pregnancy-related deaths comes from Sub-Saharan Africa [11].If established interventions were to be rendered to 90% of families in Africa each year, it is approximated that four million African women, newborns, and infants would survive [12].However, it is suggested by the Demographic and Health Survey (DHS) in Ghana that not even up to 40% of births get supervised by skilled birth attendants mean while 43% of deliveries are supervised by untrained persons outside health facilities [5].Research suggests that facility delivery is influenced by how women are cared for during delivery.For example midwives attitude such as being impatient, not supportive during delivery, yelling at women during delivery and being too harsh on women during labor and childbirth influence their choice of where to deliver [13,14].Furthermore studies in Ghana shows that physical abuse, and verbal abuse occur in facility deliveries which is confirmed by landlords, health professionals and women who deliver in these facilities [14].Studies further shows that delay in seeking facility deliveries is attributed to fear of abuse by women during facility delivery by health care providers [5,15].This findings were confirmed by this current study because all the women said they delayed in the house and didn't want to report early to the hospital.This phenomenon was also reported by Human Rights Watch in South African, where not less than 30 women said they were physically and verbally abused by being pinched, slapped and handled roughly during labor by nurses [16].
Talking about the concept of care from the viewpoint of patients, health care workers and families of patients, Shafiee et al., weighed the viewpoints of diabetic patients, healthcare workers, and the families of the patients concerning the challenges in blood glucose monitoring.They found major differences among their views and concluded that these differences brings about the failure of diabetes control in patients [17].In this regard, the concept of nursing quality was also compared among nurses, doctors and patients and found disagreements among these groups regarding the concept of nursing quality.This study concluded that the disagreements among these groups made the health care staff not able to enhance the quality of care expected by patients and thus the patients were not satisfied with the care rendered [18].
Against this background therefore it is important to consider the viewpoint of the concept of care from the woman going through labor so as to be able to formulate targeted, personalized, patient-centered care for this patient group.Studies have focused on how to manage labor pain and labor pain perceptions by women in Ghana but fail to consider the lived experience of nursing care during childbirth and the concept of care from the viewpoint of the laboring woman.This current study is the first of its kind using a phenomenological study to unravel the meaning and concept of nursing care from the viewpoint of the woman in labor in Ghana.According to Thorne, 2016, phenomenology is a good method for discovering obscure concepts, including the concept of care, in nursing and other health-related professions [19].Hence, using the descriptive phenomenological method, the researchers decided to investigate the concept of care from the viewpoint of women who have experienced nursing care during labor and childbirth.This method will allow them to tell their stories and experiences freely for the concepts of care from their views to emerge.

Material and Methods
A qualitative descriptive phenomenological method was ISSN: 2581-7493 used to conduct this study because it allows the researcher to explore an experienced phenomenon in detail.This approach was therefore used to gain an in-depth understanding of the concept of care from the view point of postpartum women in Ghana who have experienced nursing care during childbirth since much is not known about the phenomenon in the context of Ghana.

Setting, Sample and recruitment
The study was conducted at the Tamale Teaching Hospital in Ghana, in 2020 after an ethical approval was obtained.Data was collected between August and October after an ethical approval letter with reference number TTH/R&D/SR/088 was granted.Participants were recruited from the Labor ward of the hospital through a purposeful sampling since the aim was to select individuals who have experienced nursing care during labor and childbirth.The inclusion criteria were (1) Having experienced child birth within the first six month of delivery (2) Being able to speak English or Dagbani (3) Having had a spontaneous vaginal delivery and exclusion criteria were (1) Birth through a caesarian section (2) Those who could not speak English or Dagbani(3) Pregnant women with co-morbidities.In all 10 participants aged 22 to 35years agreed to participate in the study.Table 1 below represents the demographic characteristics of participants.

Data collection
All interviews were recorded following permission from the participants and was done in a quiet place in the labor ward.A semi-structured face to face interviews were conducted in order to allow participants to express themselves regarding their experiences of the nursing care provided to them during labor and childbirth and their concept of care.The interviews begun on the 5 th of August till 15 th October 2020, when saturation was reached and no new information was being gathered.The interviews lasted between 30 to 45 minutes and were each transcribed verbatim afterwards.Some interview questions were used as an interview guide and also some probing questions such as "could you please explain further what you mean by that?", "please can you give an example of what you mean by that?" were asked.The interview guide are uploaded as supplementary files.

Data analysis
Using Colaizzi's seven-step approach, data analysis was done as follows: (1) There were several readings of the Participant's descriptions in order to get more familiar with the descriptions.
(3) Meanings were formulated from important expressions that were written out.
(4) Similar themes that were constructed were grouped based on their similarities.
(5) Then out of that eight subthemes were formed (6) Following that, similar sub-themes were grouped in larger clusters and three main themes emerged.
(7) Finally in order to ensure accuracy of the findings, they were returned to the study participants for confirmation to make sure the data gathered and impressions formed represents participants expressions and experiences.

Trustworthiness of the study
Rigor helps to determine the trustworthiness of the data.Four criteria used to assess rigor in qualitative research are (a) credibility, (b) transferability, (c) dependability, and (d) confirmability [20].These four standards and their principles were applied in this study.Credibility in this study was achieved through prolonged engagement with participants, persistent observation of participants during interview, triangulation of data sources, peer debriefings, and member checks.The researcher created a conversational environment conducive for prolonged engagement by assuming a position of genuine attentiveness and openness that allows the unrestricted flow of information between the participants and the researcher.
Transferability was ensured through a rich description of the setting, participants, and themes.The researcher provided a deep, vivid description of the study process, collaborator relationship, and study context which enable others to determine how the findings may apply to other groups.
In order to ensure dependability, a log containing a detailed chronology of all research activities was maintained, narratives were transcribed verbatim, and a reflective journal was used to examine potential bias of the researcher.

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Confirmability was ensured by ensuring that content and findings are indeed from the study data and not the beliefs and biases of the researcher [21].Data was sent back to the participants for them to confirm that findings were actually coming from them and truly represent their experiences.

Ethical considerations
This research was approved by the managers and the research committee of Tamale Teaching Hospital.Participants were asked to sign an informed consent form after a written as well as verbal information was given them regarding the purpose of the study and the content of the consent form.By clarifying the purpose of the study and providing full information on how the data would be used, the research team assured the study subjects that their participation in the study would not impact the quality of the care they receive.Moreover, all participants were assured that their identities would remain confidential during the analysis and reporting of the data to protect their privacy.However consent for publication of their data was sort.They were also made to know that they can willingly withdraw from the study at any time if they so wish without any consequences.Ethical considerations were explained to the participants and verbal permission to record the interviews was taken before each interview.Each woman signed a consent form after understanding the content of it.

Results
The sample of this study consisted of 10 postpartum women aged between 22 to 35years (Table 1).Analysis of the interview transcripts depicting the women's experience of nursing care rendered to them during labor and delivery and their concept of care revealed three main themes: There is therefore, the need to consider these concepts which they consider as care when planning for care of this patient population.Table 2 represents the meaning units, subthemes and themes.
From the perspectives of women who have experienced nursing care during childbirth, the care phenomena was defined by the formation of concepts such as emotional, physical and informational support, pampering and nice communication and cordial relationship.The concept of emotional, physical and informational support was conceived by having the feeling of receiving emotional and psychological support such as sympathy, empathy, love and updates of labor progress from the staff.Also the laboring women considered pampering and nice communication that is talking nicely to them without insulting them, showering praises and giving complementary remarks to them for efforts they put in to give birth as well as teach them things they don't know in a friendly atmosphere as good nursing care.The other thing they considered as care was experiencing a cordial relationship which they expected the staff to create.

Emotional, physical and informational support
Due to the physical and emotional effects the women experience during labor and delivery, they expected the nurses and midwives to give them psychological and emotional support by being empathic and sympathetic as well as offer physical support since they are susceptible to exhaustion and also providing them with information regarding the progress of labor.These participants considered nursing care to be good if only the care includes these three categories of support:

Meaning units
Subthemes Themes They felt sorry for me and showed concern Frequent checks on me, monitoring me, standing by me, always available and the way she cleaned me nicely after delivery and supported me to walk to my bed.
Oh please kindly lie down this way and not that way with a smile.Your labor is progressing well.

Pampering and nice communication
Participants of this study considered pampering and nice communication as a very important aspect of their care.They expressed a major concern regarding how staff communicate to them.The tone and voice of their language.They love being pampered, complemented, praised and efforts they put in being acknowledged.What they dislike most is insulting, disrespecting and shouting on them when being spoken to.

Participant 3 "Yes, they were very caring because they don't shout on us. You know some nurses don't have patience and every little thing they will be shouting, insulting and those things, but here I didn't see it". Participant 4 "Actually if someone takes care of you and does not insult you or speak any how to you, you won't say her care is not good but if she insults you then you will say that the person is not taking good care of you and she does not show concern about you but since I came I have not observed that"
Participant 5 "They were friendly and just pampering me.Sometimes it seems when they are unfriendly and abusive it increases the pain but with pampering you get things easy.Just like the way they were talking to me nicely, begging me to cooperate with them, pampering me until I delivered, this gave me joy and happiness and before I realized I delivered but sometimes you can come and the bad attitude and mishandle will be too much"

Cordial relationship
Another issue that emerged as care and dear to the hearts of the women was the cordiality of staff and environment.They considered it as a concept of care.They love an environment that is welcoming, loving, accepting them and being friendly.

Participant 2 "Yes, truly I feel safe because the way the madam (midwife) treated my husband and myself on arrival made me feel that I was in safe hands. It made me feel that some friends are more than relatives. Because we hadn't even arrived and the madam quickly met us and with smiles welcomed us, took our bag from us and opened it and looked for the necessary things I needed for the delivery and explained things to us. So this action made us happy".
Participant 8 "The relationship between you and the staff where there is no shouting but friendly atmosphere.There should be that love, care and concern towards you.It should be a relationship where you feel at home.Every woman will wish that when in labor there would not be shouting on her from the midwife.Also it should not be like you become fed-up with each other" Participant 7 "Humm well, what I will describe as good care is when I came the way they received me and then how the nurses were interacting with me is something that I really appreciated and I am very happy, when I came, you know some of them will see you they won't smile, and they will frown their faces but immediately I came with my husband they started, oh lets help her, let's do this and that for her, she is in labor, go and change your dressing then they started laughing and saying; this one 'dear' you won't give birth now, like in the form of jokes and they were all laughing and smiling with us.Yeah, it was something that I felt, like I was with people.So it was easing my pain somehow".Participant 9 "Yes, you see some people are there when they are in pain they shout and make noise a lot and in that instance they (nurses) shout on them.Sometimes asking them to stop that because the midwives have nothing to do about this pain, and that it is normal so in such instances there should be respect for the woman in labor and some sort of pampering, let the person feel she is accepted and loved because some words are there when they are used on you it is not good.There should be a sort of relationship between you as if you already know one another.There should be sweet talks in between you"

Discussion
The participants in this study considered emotional, physical and informational support, pampering and nice communication and cordial relationship as good nursing care.The first theme of the findings in this study is congruent with [22].WHO defined labor support and categorized labor support according to Lazarus' definition of social support, which includes three categories: emotional, tangible, and informational support.Research evidence shows that women can suffer psychological problems during labor and child-birth [23][24][25].This calls for the need for psychological support for the woman in labor.This further underscores the need for these three categories of support from the midwife for the woman in labor.The participants in this study emphasized a lot about this support in their statements and is the reason why healthcare providers should take into consideration the emotional, physical and informational support when planning for the care of women in labor.This findings confirms what this current study found that women in labor considered emotional, physical and informational support as good care.The participants also stated that physical support such as helping the laboring woman to walk or position herself, cleaning up the woman nicely after childbirth and physically keeping the woman comfortable are important aspect of good nursing care.They also noted that informational support like updating the woman on the progress of labor and teaching the woman things she does not know regarding the process of labor is also very important for them.In this regard a research by found that among the categories of support, emotional is the most important followed by informational and lastly by physical support [26].This means that women expect all of these supports from midwives when they report for childbirth.

Pampering and nice communication
Pampering and nice communication was one of the themes that the participants of this study considered as a concept of care.They emphasized that communicating to them in a nice way devoid of verbal abuse, insults and being shouted at is good care to them.
Study by, showed that poor support and communication during labor and birth is associated with a higher rate of postnatal mental health problems including postnatal depression and post-traumatic stress disorder [27][28][29].This underscores the importance of good, effective and a nice way of communicating with women in labor and childbirth and hence confirms the findings of this current study which found that women in labor abhorred being spoken to anyhow, insulted or being shouted at.
In addition according to the dignity of a patient may be threatened if the midwife's communicative behavior sounds authoritative [30].The findings in this study was that women abhorred being shouted at and insulted which also confirms what studies indicate that nurses have been relating poorly to patients in ways that affect their dignity such as ignoring patients and talking to patients in harsh manner.Further the current study is in line with a qualitative study which used focus group discussions with women and men including health staff to determine perceptions of delivery care in Nigeria, which revealed that majority of the women in four groups in two communities abhorred the communicative behavior of hospital staff toward patients, stating rudeness, shouting and scolding as instances [31].
It is therefore crucial to consider the concept of pampering and nice communication when planning for the care of women in labor and delivery.This is imperative because mental health problems including postnatal depression and post-traumatic disorder can be avoided in these women if their care takes into consideration the way they are being communicated to.This is backed by the findings that poor support and communication during labor and birth is associated with a higher rate of postnatal mental health problems including postnatal depression and posttraumatic stress disorder [27][28][29].Hence effective and nice way of communicating is vital in maternal care and in the labor ward.It is however, worthy to note that the findings of pampering which these women love to have during childbirth is considered as good nursing care and is unique to this study which has not been published in past research findings.

Cordial relationship
Another theme that emerged as good care according to the participants in this study was cordial relationship.They emphasized that the relationship created by the health staff is important in a safe and successful childbirth.They were of the view that even though they and the midwives are not known to each other it is important that when they come seeking their professional help they should treat them as if they already know one another.Most of them emphasized the importance of warm reception and creating friendly, cordial and congenial atmosphere.This made them feel they were being accepted and welcomed and are free to express themselves and ask questions without fear or intimidation.
In respect of this, research have been conducted to demonstrate how standard of care and of relationship, are of substance and foundational to a woman's birth experience.For example, Hodnett, in her systematic review of 137 research studies, unravelling women's experience of birth, identified four (4) main elements that were very important in their evaluation and judgement of their birth experience [32].Two of these elements concerns relationships: the quality of relationship between the woman and caregiver and the degree of support given by the caregivers.Also, studies conducted by pointed out that the anxiety of childbirth is mostly determinant on past negative experiences of care, and that excellent relationships with caregivers is central to positive experiences [33].Similarly state that anxiety of a woman's child birth is mostly from previous negative experiences and a major element is the absence of quality in the relationship with care givers [34].All these research findings confirms why the participants in this study considered cordial relationship as good nursing care.Walsh and Downe also emphasized what child bearing women expect, stating that major concerns for women are having a safe birth, having a relationship from care givers that are supportive and being treated with dignity and respect [35].All the mentioned studies above regarding the importance of the relationship between the midwives and the woman in labor agrees with the current study where the participants said cordial and good interpersonal relationship between them and midwives is good care to them.It is therefore important that midwives, nurses, doctors and other healthcare workers when planning the care for women in labor and childbirth take into consideration the kind of relationship that should exist between the midwives and the women in labor.This relationship should be none other than one of cordial and good interpersonal relationship.

Conclusion and Implication to Nursing Practice
The findings of this study: emotional, physical, and informational support, Pampering and nice communication and cordial relationship answers the research question what is the lived experience of the woman in labor with regards to the rendered nursing care?For the participants what constitutes good nursing care is nothing other than emotional, physical, and informational support, pampering and nice communication, and cordial relationship.The clarion call to nurses, midwives, doctors, and other health workers who find themselves in the position of helping the woman in labor to deliver is to take into consideration these concepts which they consider as good care when planning for the care of these women.Also, it was noticed that nurses and midwives kept on telling women in labor that they should bear the pain as it is because there is nothing they can do about it, this practice should not be encouraged to continue because nurses can teach women pain relief techniques or strategies to reduce the pain.Lastly, research should be conducted to find out more reasons apart from abuse why pregnant women always want to delay in the house and

( 1 )
Emotional, physical and informational support (2) Pampering and nice communication and (3) Cordial relationship and eight sub-themes.The findings of the present study provide insight into what care is from the view point of the woman who have given birth and have experienced nursing care.
(a)Being sympathetic and empathic (b)Giving due attention and physical support (c) Give updates on labor progress and instructions in a friendly manner.Emotional, physical and informational support Your strong, you are good, well done, you're brave, you can do it, you can make it, when they use those words and also congratulate you, it encourages you.Teaching and explaining things without insulting or shouting.(a)Sweet-talks, complements, and showering of praises.(b) Avoidance of verbal abuse Pampering and nice communication.They showed love, patience and friendly atmosphere.Being interactive, being nice, and getting to know you.Didn't frown their faces, they were laughing, they were smiling and accepted us.(a)Being warm-hearted (b)Establish good rapport (c) Being welcoming and receptive.Cordial relationship

Table 2 :
Meaning units, subthemes and themes.Humm the only thing I would have preferred would have been for somebody to be rubbing my waist because that eases my pains and for me that is good car.And also to be telling or updating me about the progress or otherwise of the labor".