Review question/objective

The objective of this review is to identify the best available evidence related to how women experience birth care provided in freestanding midwifery units and in alongside midwifery units.

Background

Midwifery care is supported and influenced by philosophy. Two key schools of thought on childbirth have been identified in midwifery care, namely, physio-social midwifery and the medico-technical approach. In the first approach, childbirth is seen as a normal social event taking place as a family event that should not be disturbed unnecessarily. However, according to the medico-technical approach, birthing is seen as an event permeated by risks that requires medical intervention.1

Dissatisfaction with the medico-technical approach to birthing care usually adopted in hospitals and maternity wards has motivated the implementation of freestanding midwifery units (FMUs) and alongside midwifery units (AMUs). Alongside midwifery units are midwifery care facilities located alongside another health care facility such as a hospital. These birth care facilities were implemented in the early 1960s to 1970s in the United States of America (USA),2,3 and spread to Australia and European countries.4 Since 1999, the Brazilian federal government implemented the model of birth care adopted in the AMU as a public policy to be followed across the entire country.5,6

A growing body of knowledge on midwifery models of care exists that guide practice and education. Some midwifery models of care implemented in the USA, New Zealand, Scotland, Sweden and Iceland have been analyzed and these show consistency in the philosophy behind these models, although variations related to cultural differences have been noted. In summary, the midwifery model of childbirth care is supported by four key elements: consideration of the pregnant women's cultural background and personal care preferences; the reciprocal relationship between women and care providers (presence, affirmation, availability and participation); grounded knowledge (different types and embodiment of knowledge, and knowledge in relation to women); and an atmosphere that promotes calmness, trust, safety, strengthening, support and normality of the labor and birth. The midwife needs to perform a "balancing act" involving these elements and corresponding components to create women-centered care. FMUs and AMUs are care settings where the pregnant women are attended to throughout their pregnancy and the post-partum period, including neonatal care. The midwifery model of care is adopted in these settings, and the midwives' interventions during labor and childbirth are restricted to their essential needs.7

The implementation of FMUs and AMUs represented a revolution in childbirth care in several environments, where the medicalized model has predominated for a long time.8 The improvement of the quality of childbirth care, the confidence of pregnant women and their families, the humanization of care, and the notion of the pregnant woman as the person assuming the main role in the birthing process are the principles of FMUs and AMUs.3,5

The results of systematic reviews focusing on women's experiences related to childbirth care have demonstrated the safety of birth and high rates of satisfaction towards childbirth care provided in FMUs and AMUs.9,10

In several countries, the implementation of FMUs and AMUs has provided more options of childbirth care for pregnant women. Considering the overall variation in the adherence to the philosophy supporting normal birth care and the myth surrounding female choice in birth care,11,12 a systematic review focusing on this topic is important.

This review proposes to systematically evaluate the experiences of childbirth and childbirth care by pregnant women who attend FMUs and/or AMUs. In this review, the experiences of these women will be considered, independent of their age. Several aspects will be considered, including physical, emotional, social and cultural perspectives. An initial search of the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports and CINAHL found no reviews, concluded or in progress, focusing on women's experiences of childbirth and childbirth care in FMUs and/or AMUs. A preliminary exploration verified the existence of primary studies on this topic that included women from diverse cultural and ethnic backgrounds.

In this systematic review, the following definitions will be used:

AMU: a clinical facility where care is offered to women during labor and birth. The midwives are the primary professionals responsible for care. Medical services, including obstetric, neonatal and anesthetic care, are also available, if needed, in the same building or in a separate building on the same site. The necessary transfers are performed by trolley, bed or wheelchair.13

FMU: a clinical facility where care is offered to women during labor and birth. The midwives are the primary professionals responsible for care. General practitioners may also be involved in care. Medical services, including obstetric, neonatal and anesthetic care, are not immediately available, but these resources are located on a separate site if needed. Transfer is normally done by car or ambulance.13

Midwife: a person who has completed a midwifery education program that is recognized in the country where it is located. This care provider has acquired the qualifications to provide childbirth and neonatal care, is registered and/or legally licensed to practice midwifery and use the title "midwife".14,15

Nurse-midwife (NM): a person who is educated in both the disciplines of midwifery and nursing. Nurse midwives and midwives are professionals who work in partnership with women and provide the necessary support, care and advice throughout the pregnancy, labor and postpartum periods. They take responsibility for the normal birth and provide care for newborns and infants.14,15

Inclusion criteria

Types of participants

This review will consider studies that include women (of any age) who have given birth, regardless of parity, from any cultural background. Women who have suffered brain disorders, spine injuries or mental/cognitive deficiencies will be excluded from the review.

Types of intervention(s)/phenomena of interest

This review will consider studies that describe the experiences of childbirth and childbirth care by women who have given birth in FMUs and/or AMUs.

Types of outcomes

This review will consider studies conducted in various social and cultural settings. All experiences of childbirth and childbirth care of the women will be considered, independent of the location of the FMUs and/or AMUs they attend.

Types of studies

The review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken, followed by an analysis of the text words contained in the title and abstract and of the index terms used to describe the article. A second search using all identified keywords and index terms will be conducted across all included databases. Third, the reference lists of all identified reports and articles will be searched for additional studies. Studies published in English, Portuguese, Spanish and French will be considered for inclusion in this review. Only studies published after 1970 will be included in this review as the first FMUs and AMUs were implemented in late 1960 and early 1970.1

The databases to be searched include PsycINFO, the Brazilian Database of Nursing (BDENF), Caribbean Literature on Health Sciences (MEDCARIBE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Latin American and Caribbean Health Sciences (LILACS), PubMed, SCIELO, The Spanish Bibliographical Index in Health Sciences (IBECS), and Scopus.

Grey literature will be accessed by exploring relevant worldwide web pages to find technical reports from scientific research groups and working papers from research groups or committees. The search for unpublished studies will include Dissertation Abstracts International, the University of Sao Paulo Dissertations and Theses and primary studies obtained through requests to the authors. In each identified article, the search of reference lists and hand searching using internet resources will be conducted.

The initial keywords used will be birthing centers, life change events, life experiences, childbirth.

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data extraction

Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.

Data synthesis

Qualitative research findings will, if possible, be pooled using JBI-QARI. This process will involve the aggregation or synthesis of findings to generate a set of statements that represent the aggregation by assembling and rating the findings according to their quality. These findings will be categorized based on the similarities in meaning. These categories are then subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. If textual pooling is not possible, the findings will be presented in narrative form.

Conflicts of interest

The authors have no conflicts of interest to declare.

Acknowledgements

The Conselho Nacional de Desenvolvimento Cientifico e Tecnologico (CNPq-Brasil) for doctoral fellowship.

References