Healthy Mothers, Healthy Children: A Keystone for Happiness in Society

Abstract

Healthy mothers and children are essential to happiness in society. Birth is one of the most complex experiences in a woman’s life and the transition to parenthood is an intense period with great rewards but also numerous challenges that might negatively impact the health of the mother, the fetus, and the neonate. A positive birth experience has a fear-reaching effect on mothers’ and babies’ health and wellbeing. Perinatal education empowers women to cope with the changes and challenges of pregnancy and childbirth. Psychological and social risk factors during the perinatal period increase the risk of adverse obstetrical, neonatal, and postnatal complications, while their persistence into the postnatal period compromises mother-child interaction, and the child’s physical and neuropsychological development. The aim of this chapter is to examine perinatal care in Cyprus, starting with an outline of perinatal education and continuing with an assessment of mothers’ self-reported experiences of perinatal care received. The main objectives are: (1) to explore the mechanisms by which timely and accurate information during pregnancy can decrease the risk of adverse obstetrical, neonatal, and postnatal complications, (2) to assess mothers’ needs, and (3) to identify factors in perinatal care that lead to positive birth experiences, family wellbeing, and happiness.

1. Introduction

Happiness is a mental or emotional state of well-being and happy individuals tend to interpret and process feelings in a positive way [1]. Pregnancy and childbirth cause a wide range of physical, mental, and social alterations in women. Pregnant women’s perceptions and attitudes toward pregnancy are important due to their impact on the individual’s mental and emotional well-being [2]. Psychologically healthy women consider the pregnancy as a manifestation of self-actualization [3], feminine identity [4] contemplate gestation as a unique experience, and in most cases feel happy during pregnancy [5].

The birth event itself is a pivotal experience in a woman’s life and the transition to motherhood is a multi-level endeavor that influences many aspects of psychophysiological wellness and happiness [2]. In particular, a long-term sense of self-efficacy, what may be termed ‘empowerment,’ has the potential to be either critically enhanced or critically eroded during this time, via the birthing experience itself, but also through the woman’s overall quality of life during the perinatal period [6]. The time leading up to the birth event, the period of recovery and bonding with the neonate which follows, are times of extraordinary physical and psychological fluctuation and change, as well as cognitive development or adjustment [7].

It is not undue to liken a woman’s birthing journey to a type of second adolescence–a key developmental milestone, marked by intense bodily changes, fluctuating feelings of expectation, growth and uncertainty, and an emerging identity which determines long-term happiness for the woman herself and influences the trajectory of the family ecosystem [6]. Clearly, it is a period that ought to be skillfully navigated, ideally with adequate support structures already in place, and with ease of access to expert individualized care, perhaps particularly so in the case of a prim gravida.

As with other transitional life events, the perinatal period offers potential for joy and well-being, but it is also a period of heightened vulnerability to various stressors [7]. Birthing itself is viewed by many women as a liminal experience, regardless of low-risk designation. In this context, a feeling of uncertainty over outcomes and re-activation of past traumas can become especially salient for many women [8]. Feelings of anxiety may negatively impact labor progression and the general physical and psychological health of the pregnant mother, the fetus, the neonate, and the family unit [9]. Effectively addressing these normal feelings, preventing them from escalating into phobias, learning and practicing new health-promoting habits and coping skills, and re-kindling a sense of embodiment and internal locus of control, gain paramount importance [7]. Coming to a carefully considered, conscious, informed choice about mode of birth is vital, as is access to evidence-based information at each decision-point [10].

1.1 What is an informed choice about mode of birth, how does it relate to happiness and why advocate for it?

Informed choice is predicated on relevant and balanced information [11]. Women during the perinatal period negotiate a complex array of decision points regarding mode of birth [10]. In this chapter, we shall discuss three basic modes of birth: normal birth, cesarean section (CS), and elective cesarean section (ELCS).

The term ‘normal birth’ has become a controversial one in the current increasingly medicalized birthing climate [12]. While cultural and socio-economic factors play a role in determining birth choice, there is still a majority of women around the world who express the desire to “birth normally” [13, 14]. Normal birth should not be confounded with vaginal delivery. The term “normal birth” encompasses vaginal delivery but is not limited to this descriptor. In its comprehensive definition, “normal birth” refers to a physiological birthing experience with minimal intervention, including avoidance of excessive monitoring, induction with synthetic hormones, routine episiotomy and IV placement, artificial rupture of membranes, favoring non-pharmacological techniques for labor pain management, mobility, choice of birthing position, spontaneous eating and drinking, and non-extractive delivery [15].

Numerous studies have shown that normal birth is associated with better physiological and psychological outcomes for mother and infant [15, 16, 17, 18, 19, 20]. Normal birth is an inevitable physiological process which has many positive effects, such as timely first contact of mother and newborn, which is crucial for mother-child attachment and the child’s optimal psychological development [16]. Recent studies have shown that initial mother-child interactions, such as skin-to-skin, seeing, holding, and feeding the newborn are critical to the psychobiological process of bonding [17, 18, 19]. Positive effects have been documented on the newborn’s thermoregulation, stress reactivity and autonomic functioning [17, 18, 19, 20]. Normal birth has been correlated with prolonged breastfeeding duration and reduced risk of postpartum hemorrhage [21]. The birth experience also has numerous implications for the psychological health of the mother [22].

Cesarean section (CS) is an emergency procedure for saving the lives of women and newborns [23]. Planned CS is also medically indicated for saving the lives of women and newborns from pregnancy and childbirth-related complications, such as umbilical cord prolapse, abnormal lie and presentation, uterine rupture, fetal asphyxia, eclampsia and HELLP syndrome, failure to progress in labor and pathological cardiotocography [23, 24]. Elective cesarean sections (ELCS) are cases where women determine their own acceptable risk level and opt for CS births in the absence of any medical indication [25]. Women who make this choice perceive CS to offer the advantage of enhanced safety and minimized risk, due to the fact that surgery is a controlled, fully planned procedure managed by a medical expert [26].

Most of the women who deliver by CS report substantially lower satisfaction with the birth experience [24] and less positive memories of the birth [25]. Negative birth experiences are associated with postpartum depression, post-traumatic stress disorder, and a preference for CS in future pregnancies [22]. CS is also associated with increased risk of uterine rupture in subsequent pregnancies, longer recovery time, longer hospital stays, effects on breastfeeding, pain at incision location, mother and child complication with anesthesia and other heightened maternal risks compared to natural delivery [24]. Babies born by CS have different hormonal, physical, bacterial, and medical exposures that alter neonatal physiology. Short-term risks of CS include altered immune development, increased likelihood of allergy, atopy, and asthma, and reduced diversity in the intestinal gut microbiome [23]. Enhanced preparation and communication and an evidence-based risk-benefits analysis, can reduce women’s distress and improve satisfaction with a CS birth [27].

Whether birth mode is normal, emergency, or medically indicated CS or ELCS, self-reports consistently demonstrate that women want a satisfying birth experience. Positive birth experiences have far-reaching implications in a woman’s life through safeguarding physical health but also through the psychological pathways of increased self-efficacy [28], sense of mastery and competence [29], achieving a peak experience [30], and increased confidence as a new mother [31].

1.2 Growing tide of medicalized birth

In the current birthing climate, it can be argued that vaginal, un-medicalized birth, is not in fact the worldwide norm any longer. According to the World Health Organization (WHO) [32], 21% of births worldwide happen by CS, up from around 7% in 1990. In many countries, interventions and managed labor techniques are automatic protocols, adhered to regardless of individualized risk assessment of a woman’s potential to birth without complications. In many places, even women at extremely low risk are not diligently informed of their right to consent in these precautionary interventions, either in the educational period leading up to the birth or at the birthing facility following the onset of labor [33].

In addition to the shrinking definition of “normal” birth and the dramatic rise in CS deliveries, some countries have seen a steep rise in the phenomenon of non-emergency ELCS. Cyprus is one such country and can therefore be used as lenses for understanding systemic elements that drive and normalize such a hyper-medicalized birthing culture [33]. While the World Health Organization (WHO) has long stated that the emergency CS rate should be between 10% and 15%, in stark contrast, Cyprus has a rate of 56% (2014–2018). This –the highest rate of birth by CS in Europe [32, 33]– comprises a large proportion of cases of non-medically indicated ELCS. Correlated with this Cyprus has a very low breastfeeding rate. The “BrEaST start in life” project was a nationwide study jointly carried out by the Cyprus Breastfeeding Association and Nursing department of Cyprus University of Technology showed that fewer than 20% of women in Cyprus breastfeed exclusively even 48 hours after birth and fewer than 5% for 6 months, which is the WHO’s recommendation [34]. The project also showed fragmented and suboptimal practices across Cypriot maternity clinics in the context of promoting and protecting breastfeeding [35].

The causes for this exceptionally medicalized birthing culture, in which non-emergency managed labor has become a statistical norm, are complex and certainly not adequately explained by the wishes and autonomous choices of women [33]. Contextual factors beyond the scope of the individual woman are at play, including commercialization of medical service provision and a health system skewed toward maximal risk aversion. In this context, many midwives feel it is their ethical duty to advocate for women at low risk of birthing complications who desire a psychologically safe, non-medicalized birthing experience [36].

As part of this venture, two first-time studies on perinatal care were undertaken recently in Cyprus. One is an ethnographic study that has yielded a preliminary description of the culture of parenting preparation classes in Cypriot public and private birthing facilities. The second is a participation in the EU-wide Babies Born Better (BBB) survey which has yielded self-reports of women in Cyprus on their positive or negative birth experiences.

2. Overview of two studies in the cyprus context

2.1 Ethnographic outline of perinatal education in Cyprus: description of the culture of parenting preparation classes in public and private birthing facilities

Pregnant women want to receive comprehensive antenatal education and nulliparous women need opportunities for guidance and transference of knowledge, skills, and attitudes toward perinatal care from midwives [37]. Birthing preparation and parenting classes are vital components of quality antenatal care, guiding parents to be and parents toward health-promoting decisions during pregnancy, childbirth, and postpartum [38, 39]. Antenatal education has the potential to profoundly influence birth expectations [39] and has been shown to have a positive effect on the health of the family as a whole, by reducing anxiety in pregnant women and increasing partner engagement during labor and birth [40]. A significant factor in happiness is partner relation and marital status [4].

Antenatal classes provide basic knowledge and skills aimed at improving women’s health, reducing the risk of complications, and securing a positive experience of childbirth for couples [41]. However, some countries’ birthing and parenting classes do not meet these learning aims and educational needs [42, 43]. In Cyprus, antenatal classes are currently offered by the national health system for free and by a few privately operated maternity units, at a cost. Commonly, in the public sector, midwives are responsible for the organization and coordination of antenatal education programs, whereas, depending on the site and the curriculum, a range of health professionals may be involved as instructors in private clinics, such as gynecologists, pediatricians, psychologists, nutritionists, physiotherapists, and others. The structure and curriculum of these programs are not regulated by any central body and as a result, there is considerable variation. Despite numerous studies showing the benefits of antenatal education worldwide [41, 42, 43], evidence of the impact of antenatal education in Cyprus is not well-researched. This initial ethnographic study is therefore particularly useful, because it identifies the educational needs of parents-to-be, while simultaneously exploring the effect of prenatal educators’ characteristics and the physical learning environment on participants’ self-reported satisfaction with the classes.

In order to portray the culture of the antenatal classes in Cyprus, overt non-participant observation was employed by the researcher. The study involved 171 pregnant women and 125 spouses/partners who attended 19 preparation-for-parenthood classes at three separate sites, one public and two private. The participants were informed about the researcher’s role and the researcher took field notes during the lessons and used a reflective journal to comment on the experience following each session. The researcher did not contribute to discussions during the antenatal classes.

Data were extracted using multiple methods common to ethnography. Through field notes and the reflective journal, the researcher recorded what happened at each session; the attendance rate; the profile of the attendees; the activities and interactions; and the pregnant women’s feelings. Twelve telephone interviews were conducted with the pregnant women after the completion of the antenatal classes. The interviews took the format of a semi-structured interview, based on a recent related literature review. The interviews were digitally recorded and transcribed verbatim. The interviews aimed to draw out fine-grained information about the participants’ experiences and perceptions, and open-ended questions allowed for participants to express their experiences in whatever way was most meaningful to them. The results were used to inform and expand researcher observations. Two independent researchers analyzed the data using an inductive content analysis method, and the results were discussed with a third researcher with the goal of achieving more in-depth analysis. There was no predetermined coding scheme or framework applied to the data. Codes for ideas expressed in the transcripts, the reflective essays, and the observational notes emerged freely through inductive methods. The codes were then grouped into categories and themes.

The majority of the participating women and their partners were Greek-Cypriot. Other pregnant participants were Greek (3), Greek-American (1) and English/Scandinavian (1). The couples attended class dressed casually, most of the women came with their husbands/partners and most of the participants had a tertiary education level. Most participants seemed shy and undemanding; a small subgroup asked questions and requested clarifications, however, many participated in whole group discussions.

Analysis of the data yielded four main themes: (1) Views and opinions about the course (2) Important perinatal topics, (3) Usefulness and reasons for attending and (4) The learning journey. From the researcher’s notes, reflective diary, and interviews with participating women, a general picture emerged that although participants valued the classes, they felt their expectations had not been fully met.

The physical environment of the classes emerged as an important parameter for participants. Some of the pregnant women stated that the classroom was not learning-friendly because its arrangement and furnishings were not suitable; the chairs were uncomfortable and, on occasion, the room felt too crowded.

“It would be useful to prepare a room exclusively for this purpose … To include [pilates] balls, to include cots… and decorate that accordingly.”

The presence of fellow pregnant women in the classes offered an opportunity for mutual support. After classes women reported feeling less anxious and more confident in their capacities. Social support has been proven to be an important component of perinatal care in a similar setting, the CenteringPregnancy® group model of prenatal care [44]. Nolan study [42] has shown women’s preference for small group learning in which they are offered opportunities to interact with each other, as well as the educator, and to link the learning material to personal situations. The current study also highlighted the fact that husbands/partners were supportive throughout the process, which was very empowering for the pregnant women. It was apparent that participation in the lessons was mutually beneficial as the men gained an understanding of the pregnant women’s needs. During lessons, one midwife would ask everyone to stand up, and would direct the husbands/partners to hold their wife’s/partner’s hands in order to practice patterned breathing. This visibly aided the bonding of the couple. Most husbands/partners were absent from the breastfeeding class. The researcher hypothesized that the husbands/partners believed breastfeeding issues to be a matter which was not of their concern.

Educator characteristics were of primary importance for participants. It was evident to the researcher that the fact that instructors in various topics were professionals in their fields promoted a sense of trust and heightened appreciation for the educator. This is in line with studies that have shown that the attitudes, demeanor, skills, and characteristics of health care professionals are very important for pregnant women [42, 45]. Pregnant women in the current study likewise mentioned that the attributes of health care professionals mattered considerably [39].

“…Due to their specialized knowledge… they provided us with scientifically based answers.”

“The educators were very helpful. We could ask any kind of question… they were close to us; we did not feel uncomfortable… They were very approachable.”

The main format of the classes was lecture-style, that is, the educator presented information via PowerPoint, sometimes using audiovisual material. Some instructors gave out occasional written information in the form of leaflets or booklets, on topics such as nutrition and neonate vaccinations. Participants stated that written information was useful. Some participants, however, stated a preference for an interactive teaching style, use of props and equipment, doing exercises, group activities and role-playing, which they found to be more engaging, personalized, and suitable for developing practical skills.

Participants requested discussion of certain topics more frequently than others and nutrition during pregnancy was one such topic. Many women were highly interested and asked many questions. It was evident to the researcher that the midwives observed in this study did not have enough knowledge and skills to provide adequate or personalized advice about nutrition. This was also noted by participants in the semi-structured interview. Midwives are known to play an important role in the promotion of healthy eating, but they need support from nutrition experts in order to individually advise women on the topic [46].

Another salient topic for pregnant women and their partners was the act of birth itself. Participants asked questions about different methods of birthing, labor pain management, how to psychologically cope during labor, and the storage of umbilical cord blood. The researcher felt there was an observable need for greater detail in information given to the women on birthing methods.

“Personally, I would like to know some specific information…about the process of induced labor, how it is done… the pros and cons of a cesarean section.”

Medicalization of childbirth has led to a steady rise in the prevalence of CS in Cyprus over the past 8 years. Evidence-based, unbiased advice from healthcare professionals strongly influences a woman’s choice of birthing mode [47]. The role of midwife, as advocate for normal birth, however, is not always appreciated in Cyprus by pregnant women, the healthcare system, and the obstetricians [33, 47]. In a study conducted in Turkey, which also has a severely medicalized birthing culture, women reported they requested ELCS due to fear of labor pain [48]. This study also suggested that the percentage of women with fear of childbirth, the severity of fear, and requests for ELCS, can all be reduced when better education on labor pain mitigation and management is offered to women, and this is likely also the case for Cyprus.

The ethnographic study also determined that attendance in antenatal courses is low compared to the numbers of prim gravida per year in Cyprus and courses are not adequately promoted. Given the potential long-term health benefits of such courses for mothers as well as children, this should alarm policymakers. Birthing culture in Cyprus operates predominantly in a milieu modeled on a doctor-patient relationship and is characterized by ultimate authority of the obstetrician and physician dominance of communications surrounding pregnancy and the birthing experience. The result is that information processing for mothers-to-be is limited to brief one-on-one doctor-patient style interactions. In this context, low participation in antenatal classes becomes even more troubling.

This study identified the need for parents-to-be to be provided with more information and practical examples on important topics. Pregnant women in the study expressed the need for realistic information taught by professionals specialized in their fields. The role of midwife as coordinator of perinatal education is imperative, however, related health care professionals complement the midwife’s role. Raising the profile of public health support programs available to pregnant women has the potential to greatly improve Cypriot women’s perinatal literacy and health. Implementation of a high-quality, standardized perinatal curriculum, should be prioritized within the framework of the national healthcare system. For maximum societal health gains, such a curriculum should be oriented toward the family unit as an ecosystem, addressing the educational needs of all its members: the expectant mother, the newborn, and the husband/partner or whoever constitutes the woman’s primary support system.

A final significant theme emerging from the current study was a strongly felt gap in postpartum care. As one mother put it: “After you have the baby, you’re deserted.” The postnatal period, another important health education opportunity, as well as a potential point of contact for identifying psychosocial stress factors and offering timely interventions, is thus also a currently neglected aspect of public healthcare in Cyprus.

2.2 Mothers’ self-reported experiences of labor and perinatal care in cyprus: babies born better (BBB) survey

Several factors influence women’s experiences during childbirth [49, 50]. Sufficient information, respect, breast-feeding guidance, and skin-to-skin contact, positively affected women’s experience [50]. Staff confidence, adequate analgesia, and continuity of care also contributed positively. Health care providers’ personality and availability were other contributing factors [51]. Another survey found that during labor 69.8% of women were systematically informed of their progress; 77.6% said their vaginal examinations were done gently; 39.4% were allowed to eat and drink; 79% had skin-to-skin contact with their baby immediately after birth and 96.7% received the necessary help and support for breastfeeding. These factors contributed to 55% of women feeling fully satisfied with their care [52]. Most mothers worldwide currently give birth with interventions that affect their capacity to experience birth positively [32, 49, 53].

The second study is a part of the Babies Born Better (BBB), an online mixed survey, funded by the European Union, involving the participation of researchers from 26 European countries, as well as Australia, China, and South Africa. The project aims to enhance scientific knowledge and provide ways of improving maternity care and outcomes for mothers, babies, and families. The present study utilizes data from Cyprus’ participation in the BBB survey and project. The wider survey was conducted in two phases. The first phase was initiated in 2012 and completed in 2015. The second phase was conducted from March to August 2018, with the participation of 44,628 mothers worldwide. The Cyprus BBB study is part of the second phase where a mixed methodology was employed using quantitative and qualitative methodologies. The mixed method study included 360 mothers aged 18 and above who resided in Cyprus and had given birth in the previous 5 years. The mothers were recruited through social media and virtual communities of practice, such as maternity clinics, where they were informed of the survey by midwives.

A total of 360 women participated during the period from March to August of 2018. The majority of the participants (45.1%) were 28–33 years old and 34–39 (47.4%). Only 7.5% were older than 40 years of age. With regards to education, 73.1% of mothers had completed 11–15 years of education, 26.9% 16–20 years. According to official statistics, 67.7% of mothers giving birth in Cypriot maternity clinics have post-secondary education. With regards to employment status, 87.5% reported being employed and 12.5% reported being unemployed. Employment status and family income are not reported in official statistics to allow a comparison. The proportion of mothers with one child versus two children or more was similar: 49.4% and 47.5%, respectively.

The majority of participating mothers (72.2%) gave birth in private clinics. In terms of mode of birth, the proportion of mothers who gave birth vaginally is identical to those who underwent CS at 39.2%. The CS rate of the women surveyed was lower than the officially published general population data (56.9% in 2018). In terms of satisfaction with their birth experience, 50% of women reported they had the best experience during birth and only 6.1% said they had the worst birth experience.

Qualitative data analysis was carried out using inductive content analysis which is a systematic and objective method designed to describe a phenomenon in depth in order to make it more understandable. Five themes emerged from the inductive analysis of the data: (1) relationship with health professionals, (2) establishment of breastfeeding, (3) childbirth rights, (4) birth environment and care and (5) choice of birth mode. These themes highlight the pivotal role of health care professionals in promoting a positive birthing experience both during and after labor.

Mothers identified the experience and expertise of health care professionals as being essential to their sense of trust and safety. One mother explained:

“ My health care professionals are experienced; they have the necessary knowledge… I feel safe as I trust my doctor and my midwife during pregnancy and especially during childbirth.”

When asked what improvements they wished to see, however, many mentioned interesting examples of poor care:

“[The] doctors are thinking of money. There is no cooperation between mothers, doctors, and nurses and it seems that they do not care much.”

Mothers who reported a negative birth experience stated they felt a lack of humanity, support, bonding, and safety with their healthcare providers; an insufficient presence of the doctor; abuse of authority and psychological manipulation; a feeling of being simply a source of money; and being exploited while in a vulnerable situation. One mother characteristically stated:

“When the doctor first examined me at birth…she shouted at me that I must follow her orders. I was very shocked; no one ever spoke to me like that. Because I could not speak between contractions… I was alone and could not defend myself…I was very hurt, and I felt that I was in a vulnerable position.”

Another main issue identified by participants was the lack of maternal involvement in decision-making around the mode of birth and labor care. Women emphasized how important it was to them that their choices and desires were acknowledged and implemented. One mother described how difficult it was for her to be allowed the birth mode she had chosen:

“My choice to give birth with VBAC was a battle for me with my doctor because VBAC is not allowed at this maternity clinic, but eventually they let me give birth with VBAC.”

Another mother said her choices were partially respected: “Most of the time I could decide.” Other women spoke more positively about more respectful care. One stated that she had received respectful care from her doctor and explicit opportunities to give consent:

“The doctor respected me and always asked for my consent, he was very supportive.”

Many of the mothers surveyed asked for support toward normal childbirth, avoidance of unnecessary interventions, and performance of CS only when absolutely necessary. They specifically suggested that health care professionals should have a more humane approach and pay attention to their feelings. Mothers stated they wished to see improvements in the physical birth environment, in particular, they would have wanted to a friendly environment, to have single rooms with ensuite toilet and a bathtub, an esthetically pleasing maternity ward, and availability of natural methods of labor pain mitigation, such as music and the presence of partner. Mothers also mentioned they would have chosen a water birth. Their requests echo another study where recommendations for improvement by mothers were also related to the birth environment, with space available for natural childbirth without interventions, where mothers would have more control over their birth, and more support and understanding from health care professionals.

The evidence from the Cyprus BBB survey starkly highlights the need for change in maternity care in Cyprus, even in private clinics. Expectant mothers in Cyprus want their childbirth rights safeguarded, better support from health care professionals, and more humane care.

2.2.1 Positive experiences during childbirth

The most positively experienced category in maternity practices was “care received and experienced” with 35.4% of participants rating it as an important contributing factor toward their positive experience. The second most frequently mentioned category was “specific interventions and procedures” such as pain management with an epidural with 18.0% of respondents rating it as contributing positively. The category “Care team” was ranked third in importance with 17.3%, followed by the category “environmental conditions” with 7.4%. About 15.8% of the participants provided no information on factors leading to positive childbirth experiences.

Overall care of both mother and baby were mentioned as important criteria of a positive childbirth experience. In the category, “care received and experienced,” the subcategory “support and accompaniment” received the most responses of having been positively experienced with 30.9%. Mothers mentioned psychological support and encouragement, as well as practical and instrumental support provided to them during labor. The subcategory “overall maternity and childbirth care” was ranked second with 26.1%. The subcategory “professional behavior and attitude” was ranked with 21.83%, referring to patient-health care professional relationships and interactions in terms of kindness, care, friendliness, understanding, respect, and staff calmness. The third most frequent subcategories were “staff time and availability” and “respectful care, intimacy, and sense of agency” with 8.7%. Continuous availability of staff, frequently commented by mothers as contributing to a positive experience.

In the category “specific interventions and procedures”, 49.2% of mothers rated breastfeeding support and guidance about three times more important than normal birth facilitation without interventions (18.8%). Most responses on normal birth facilitation focused on normal birth. Good maternity practices to support breastfeeding were ranked third with 23.4%, referring to rooming-in and skin-to-skin.

2.2.2 Recommended changes for birth and post-natal care in Cyprus

Negative aspects mentioned by Cyprus BBB survey respondents were numerous and interesting (Table 1). Specific interventions were the most frequently mentioned category with 18.6% of respondents mentioning them. The category “no change required” was ranked second with 16.0% followed by “care received and experienced” with 13.5%. In the category “specific intervention and procedures”, subcategory “normal facilitation without interventions” received the most responses with 39.36%, followed by “support to breastfeeding” and “effective medical interventions” with 31.91% and 19.15%. With regards to the subcategory “normal facilitation without interventions”, the most frequent responses emphasize the medicalization of childbirth and the desire of mothers to give birth normally. In the second subcategory, “support to breastfeeding,” mothers referred to the lack of support for breastfeeding, lack of guidance, inadequate knowledge, and motivation on the part of their health care professionals.

1. Care received and experienced
Overall care received and experienced	Positive Statements: Positive assessment of the care and assistance received before, during, and after birth to the mother as well as to the newborn.
	Negative Statements: lack of care or negative evaluation
Support or help provided	Positive Statements: any type of support or help provided (Informational, emotional)
	Negative statements: insufficient or lack of any type of support or help
Effective communication	Positive Statements: effective communication with health care professionals with the use of various communication skills (e.g. active listening, guidance, advice)
	Negative Statements: no communication or lack of communication skills; a conversation among professionals without including the women
Trust and safety	Positive statements: Mothers feel secure and confident with the behavior and actions of Health care professionals
	Negative Statements: Lack of security and trust
Courtesy, Respect during Care	Positive Statements: consideration of maternal choices, needs and desires, respecting the right to choose and to decision-making
	Negative Statements: Insufficient or lack of the above. Paternalism, coercion, or threats
Professional behavior and Competence	Positive statements: When health care professionals are empathetic, thoughtful, considerate, caring, friendly, companionate, kind, attentive, dedicated
	Negative Statements: Insufficient or lack of the above attributes. Dehumanization or depersonalization
Time and availability	Positive Statements: HCPs readily available, continuous presence of HCPs (obstetrician or midwife), sufficient time and commitment provided, enough time required for labor provided
	Negative Statements: insufficient time spent, commitment, presence, availability, continuity
2. Involvement of members of care team
Involvement of health care professionals	Positive Statements: when the involvement of any health care professional with any expertise (or a specific person) has been considered to Negative Statements
Professional competence and interdisciplinarity	Positive Statements: professionalism, competence, experience expertise, qualifications, specific knowledge, and skills, interdisciplinarity, teamwork, and team dynamics
	Negative Statements: insufficient acquisition or lack of the aforementioned attributes
Presence of the partner in labor	Positive Statements: presence or involvement of a parent (or other accompanying person) at birth
	Negative Statements: poor level or lack of involvement
3. Use of interventions or processes during or after labor
Facilitation of vaginal birth without any intervention	Positive Statements: facilitation of vaginal birth with few or no interventions and absence of invasive procedures; demedicalization; free movement during labor; Consideration of birth plan
	Negative Statements: interventions value negatively (type and quantity); Non-recommended or unnecessary procedures are used. Obsolete protocols and their obligatory application
Effective medical interventions	Positive Statements: quick and timely response of medical staff during labor; reduction of pain by anesthesia; any medical intervention that is valued positively
	Negative Statements: lack of medical interventions; ineffective procedures; delayed response
Support to Breastfeeding	Positive Statements: Emotional Support/Appraisal, information (giving advice)
	Negative Statements: insufficient or lack of any kind of support
Bonding Practices	Positive Statements: skin-to-skin, rooming-in, and any practice that promotes an uninterrupted bond with the baby
	Negative Statements: insufficient or lack of any of the above items
4. Environmental conditions
Settings, infrastructure, and resources	Positive Statements: the place of birth and postnatal ward; single rooms; equipment
	Negative Statements: poor quality or lack of the above
Experience during their stay at the maternity wards	Positive Statements: general atmosphere in the labor and the ward (silence/ music, temperature, illumination); Accommodation, visiting times, cleanliness, quality
	Negative Statements: poor quality or lack of above items

Table 1.

Thematic areas and categories developed during analysis.

With regards to care experienced and received, most responses referred to Professional Behavior and Competence (27.94%). Mothers mainly referred to the need for the adoption of a more humane approach from health care professionals and the development of empathy. Second in rank was the subcategory “support and accompaniment” (20.60%), describing the need for the provision of support in many of its forms including informational and emotional support during labor. About two out of 10 women referred to the need to be listened to as far as their preferred childbirth mode and the development of a birth plan.

3. Discussion

The medicalized character of the health care system in Cyprus does not provide any of feelings of safety, support, and empathy to pregnant women and mothers. The lack of humane approach, support, bonding, insufficient presence of the doctor, abuse of power and psychological manipulation [33, 36], feeling of being sources of money, feeling of exploitation of mothers in a vulnerable condition [54] all point to the urgent need for the development of a perinatal care system that provides for inclusion of pregnant women and mothers in decision-making processes, on the basis of their explicitly expressed needs [55, 56, 57].

The first ethnographic study in Cyprus offered a description of the culture of birth preparation and parenting courses. According to the researcher’s notes, reflective diary and interviews of the participating women, there was a general impression that although the participants found the antenatal courses useful and valuable, their expectations remained unfulfilled. The physical environment of the classes, the educators’ characteristics and the limited topics covered, were the most important emerging parameters. Some of the pregnant women reported that the classroom setting was not learning-friendly because its arrangement was not suitable for such lessons; the chairs were not comfortable for pregnant women and occasionally there were too many people in the room. An esthetic and comfortable environment has been shown in a previous study to help pregnant women feel content [43].

Pregnant women expressed the need for realistic and trustworthy information. Educator’s characteristics played a major role in the opinions of participants. The importance of specialized topics being taught by health care professionals who were specialists in their fields was also highlighted. The role of the midwife in perinatal education is imperative, however other health professionals could offer educational sessions on sub-specialty topics. The presence of fellow pregnant women in classes gave women an opportunity for mutual support. It also seemed to empower women to face the normally expected risks and helped them receive comprehensive support, which in turn guided their own perinatal experience [42]. It is worth noting that in perinatal education classes there are no lessons on formula feeding. The experience of mothers who choose to use formula is largely overlooked in many countries [58]. Mothers make decisions about infant feeding based on a variety of factors, the most salient of which are infant health, cultural context, social support, practical and other implications for the mother, and knowledge about infant feeding [59]. Mothers’ criticisms of how infant-feeding recommendations are framed by health care professionals and policymakers, highlight a need to address formula feeding in a more balanced, woman-centered manner [58].

In countries with advanced development and technology-dependent healthcare systems, women’s perceived choices during pregnancy and childbirth, as well as the choice of the information offered during perinatal education are, at least to some degree, dictated and uniformly managed by the cultural norms and interests of the overarching system. In a study conducted in Ireland, most women reported not having the choice in the model or location of their maternity care, but nonetheless being involved enough in decision-making, especially during birth. Women who were in a position to receive private maternity and birth care reported a higher sense of choice and control [60]. In Cyprus, many women are, similarly, not in a position to opt for private maternity care, or determine its model or location, however, mothers-to-be expressed a sense of inadequate involvement in decision-making, be it in the public or the private care sector.

The second study concluded that the mode of birth was one of the main components of either positive or negative childbirth experience. Mothers referred to normal birth as a component contributing to positive experiences. On the contrary, CS has most frequently been viewed as a contributor toward a negative experience. Cyprus ranks first in combined CS and ELCS among other European countries at 56% [60]. Normal birth is accompanied with emotions of happiness and empowerment, while CS has been associated with feelings of fear, pain and stress, agony, and disappointment [36] often resulting in a traumatic childbirth experience.

Mode of birth also appears to influence the nature of the first moments of mother-baby contact. Normal birth is followed by an immediate sensory connection between the mother-infant dyad, but CS may either partially or wholly deprive the dyad of important sensory connection immediately after birth [12]. However, a highly significant finding showed that mothers who undergo CS but do experience skin-to-skin, have a more positive childbirth experience than those who give birth vaginally, without experiencing skin-to-skin [61, 62, 63]. Health care professionals play a critical role in either positively or negatively influencing women’s experiences of childbirth, through either the presence or absence of support, professionalism, competency, effective communication, and respect. These findings agree with previous studies, where the quality of interaction with health care professionals has been identified as a cornerstone for positive birth experiences [55, 56], embedded in a holistic health system supported by suitable facilities [64].

A supportive and respectful environment provides a sense of control and safety during labor and increases maternal self-confidence, resulting in a positive experience of [62]. According to Preis et al. [65], greater control has been associated with positive emotions, which develop as a result of maternal involvement in decision-making and provision of information on personal security and physical functioning [66]. On the other hand, a feeling of lack of control does not allow for a positive experience [62]. Women emphasized the importance of both physical and emotional support. Lack of support may lead to overall childbirth dissatisfaction and low levels of confidence, due to feelings of isolation and the devaluation of women’s needs and preferences. On the contrary, both professional and family support may enhance maternal confidence and allow women to feel that they are being considered [54].

Both studies indicate that women wish midwives to gain a pivotal role in perinatal care in Cyprus. Midwives are able to offer continuous support and guidance during pregnancy, labor /birth as well as postnatally, to create a trustful relationship and to empower women, and increase the possibility of a positive birth experience [67]. Provision of emotional and psychosocial support, practical help and guidance during labor/birth as well as postnatally has been flagged by mothers as an important ingredient for best maternity services.

The different model of care provided by midwives and obstetricians shows a preference of women toward the midwives in Cyprus. Midwives offer a woman-centered model of childbirth care [68] characterized by equality between the women and their midwives [69] and the avoidance of unnecessary interventions [70] in comparison to a more medicalized hierarchical care as provided by obstetricians and supported by the overall culture of the health care system in Cyprus [33].

4. Conclusions

Childbirth is a physiological process characterized by a plethora of emotional, physiological, and psychological changes that are vital for maternal adaptation and transition into the new role of motherhood. Mode of birth has potentially long-lasting effects on mothers and neonates’ health. Mothers who experienced CS were more likely to perceive their birth experience as negative, especially in terms of their sense of control and bonding with the newborn, and they felt more concerned, insecure, and had lower self-confidence. Several factors influence women’s experiences of childbirth such as sufficient information, respect, skin-to-skin contact, and breast-feeding guidance, positively affecting women’s experiences. Staff confidence, adequate analgesia, and continuity of care also contributed positively. Health care providers’ personalities and availability were also contributing factors.

Perinatal education enables women to experience birth as a source of empowerment and happiness. There is not always an agreement in the perception of what is important information between health professionals and parents-to-be/new parents. Expectant parents will benefit more if perinatal education emphasizes the information, they themselves seek out and feel it is important to know and expect to receive information in a more woman-centered manner. Thus, in order to design effective antenatal education programs, it is imperative to further explore the expectations of pregnant women. Antenatal education programs (conventional or web-based) must be re-designed using participatory action-research approaches, in order to take into genuine consideration, the expressed needs, wishes, and concerns of pregnant women. In underperforming settings, the need for improvement is particularly pronounced due to a lack of formal systems and policies, lack of continuity of care, ineffective and non-socially inclusive antenatal courses, and weak community support systems.

Existing examples of evidence-based, women-centered midwifery care and a longstanding tradition of deep understanding of women’s childbirth experiences, highlight the incongruity of the highly medicalized character of maternity services, such as those currently prevalent in Cyprus. In response to this, policymakers should promote a strategy for timely and accurate information to be offered to women during pregnancy so as to minimize the risk of adverse obstetrical, neonatal, postnatal complications and interventions, as well as negative experiences such as loss of control, thereby protecting happiness. In Cyprus, where care during labor and birth is highly managed and characterized by increasing intervention, it is vital to implement practices that have shown positive results in other European countries. Further research to identify mothers’ needs will lead to better individualized design of ante-natal courses and more suitable course environments. Finally, elucidating the factors in perinatal care that lead to positive birth experiences, family well-being and happiness, can support this crucial endeavor. A global approach to quality and equitable maternal health, supporting the implementation of respectful, evidence-based care for all, is urgently needed.

Midwives in Cyprus do not have a substantial amount of influence regarding perinatal health policy. This pattern is also observed in some other European countries where hierarchical structures accord obstetricians greater value than midwives. Nonetheless, midwives in Cyprus do have structured healthcare entry points and opportunities for pre-emptive intervention aimed at safeguarding informed choice and increasing the chances for women to experience birthing as a positive and life-affirming event. If midwives manage to position themselves in the existing healthcare system, as the primary providers of high-quality evidence-based perinatal education; if they can optimally design and tailor perinatal course content to maximize quality care time spent with pregnant women, they will be able to enhance the effectiveness of their role not only in shielding women’s psychosocial wellbeing but in preserving the potential for birthing to be lived as a peak lifetime experience. This concept of a “peak lifetime experience” was originally articulated by Abraham Maslow [71], who, in his theory of self-actualization describes peak experiences as “rare, exciting, oceanic, deeply moving, exhilarating, elevating experiences that generate an advanced form of perceiving reality and are even mystic and magical in their effect upon the experimenter.” If midwives can hold space for greater numbers of women to experience birthing like this, they will surely be laying a keystone for the promotion of happiness for women, children, families, and society.

Acknowledgments

I acknowledge the generosity of my MSc students Maria Frangou and Maria Andreaki for allowing me to use their data for this chapter. Furthermore, I acknowledge that the second study derives from the Babies Born Better project, which was developed as part of the EU-funded COST Action IS0907, and continued in EU COST Action IS1405: BIRTH: “Building Intrapartum Research Through Health - an interdisciplinary whole system approach to understanding and contextualizing physiological labor and birth” (http://ww.cost.eu/COST_Actions/isch/IS1405).

Conflict of interest

The author declares no conflict of interest.

Notes/thanks/other declarations

The author would like to thank all pregnant women, partners, and mothers who participated and offered valuable data. Warm thanks to MSc students for their significant contribution to identify parents to be and parent’s needs. Special thanks to Iole Damaskinos and Yianna Koliandri for their comments and editing.