Background: South Africa struggles to improve maternal health outcomes resulting to its failure to achieve millennium development goal for maternal health. Non-utilisation of antenatal health services by pregnant mothers is the leading cause of unbooked cases that complicate the labour stages. Purpose: The purpose of the study was to explore the experiences of midwives for caring unbooked pregnant women in a maternity unit at a district hospital in the Eastern Cape province of South Africa. Design and Methods: A phenomenological approach was adopted in this study. Specifically, a descriptive phenomenological deign was used to explore midwives’ experiences for caring unbooked pregnant women in maternity ward of a district hospital on six (6) purposively selected midwives. In this study, the researcher utilised individual, semi structured phenomenological interviews to collect data from midwives caring for unbooked pregnant mothers in a maternity unit. Data saturation was reached after carrying out the six interviews. These interviews were audio taped and transcribed verbatim and Interpretative Phenomenological Analysis framework steps method of qualitative data was applied to analyse the collected data. Results: Three thematic categories emerged from data analysis: 1) Experiences of midwives, which interfered with emotional challenges leading to fear and anxiety. Experiences of midwives were also associated with shortage of midwives and leading to maternal incidences. 2) Caring for unbooked pregnant mothers interfered with incompetency and inexperienced midwives and reported a lack of debriefing. 3) Support system which was seen as lacking from managers. Conclusion: The study recommended collaboration with primary health care clinics including community leaders, and employment of highly skilled professionals and in-service trainings of the current midwives to minimise unnecessary incidences.
South Africa is struggling to improve maternal and perinatal outcomes as there is a failure to attain millennium development goal for maternal health [
However, these is a revelation that women with poor socioeconomic difficulties are more likely to attend antenatal care services and they end up being “unbooked patients” during labour stages [
Further, women with good socioeconomic conditions are likely to attend their antenatal care services as a result 90% of them booked their labour stages. Therefore, improving socioeconomic status of women could minimise unnecessary maternal losses. Though South Africa has implemented primary healthcare re-engineering program to deliver services in the communities, it is still struggling to trace pregnant mothers for antenatal care services [
A study in Nigeria on unbooked patients’ impact found that these types of patients have missed potential benefits of antenatal care services and contribute into high maternal and perinatal mortality [
Comparative studies of booked and unbooked patients demonstrate that the unbooked patient is a woman with limited resources and that pregnancy outcome from unbooked clients is often high risk [
In addition, the unbooked pregnant mothers are regarded as a public concern in the African countries [
In United Kingdom, a study on understanding the delayed access to antenatal care found that there was an increase in infant, foetal and maternal mortality emanating from poor attendance of antenatal health care services by pregnant women [
A study conducted in sub-Saharan Africa on reasons of women not using antenatal care service found that the high maternal mortalities are associated with unbooked pregnant mothers [
However, Midwives are the frontline essential practitioners and the continuation of these unbearable circumstances could lead to emotional stress of midwives because in their profession unsuccessful deliveries are unacceptable and it is regarded as a crucial matter in their profession [
Universally, countries including South Africa adopted millennium development goals (MDGs) to strengthen their health systems [
The following research question was formulated: What are the experiences of registered midwives caring unbooked pregnant mothers? This was translated for the participants as: “Explain in your views, how do you experience caring and managing unbooked pregnant mothers in maternity ward?” Subsequent questions arose from the participants’ descriptions of their experience.
The purpose of the study was to explore midwives’ experiences for caring unbooked pregnant mothers in maternity ward of district hospital in the Eastern Cape of South Africa. To achieve this purpose, the researcher sought to determine and explore the lived experiences of midwives caring unbooked pregnant mothers.
The findings of the study will facilitate the formulation of guidelines for proper management of unbooked pregnant women. Equipping registered midwives with counselling, coping skills and competencies will strengthen and advance their nursing skills working with pregnant women. The study could enlighten nurse managers and policy-makers on the experiences of midwives providing management of unbooked pregnant women. Results of the study could enable primary healthcare services to improve the quality of antenatal care services.
Caring in this study refers to the compassion, usefulness, moral support and care that the midwives show about unbooked pregnant mothers who came for labour.
Experiences in this study refer to the circumstances or events experienced by midwives while caring for unbooked pregnant mothers.
Maternity unit in this study refers to an accredited health facility unit that specialising in caring for pregnant mothers during labour and delivery procedures.
Midwives in this study refers to a nurse who has registered with the South African Nursing Council as a midwife and is in possession of the appropriate qualification(s) in Basic or Advanced Midwifery Nursing Science, and who cares for pregnant mothers in a public hospital in the Eastern Cape Province.
Unbooked pregnant mothers in this study refers to mothers who have not received adequate antenatal screening in a modern health facility and have just come straight into the health facility for labour and delivery purposes.
A descriptive phenomenological qualitative study was chosen to describe human experiences of midwives caring unbooked pregnant mothers. The researcher adopted a phenomenological approach to explore the experiences of midwives through their descriptions of caring and managing unbooked pregnant mothers. These experiences are called “lived experiences”. In addition, qualitative research involves the systematic collection and analysis of subjective data provided by involved people about the phenomena, including how they interpret the experiences and meaning attached to the experience.
The population comprised selected registered midwives employed at the research site. The researcher used non-probability purposive sampling technique. This technique allows researcher to choose participants according to their knowledge and work experience on the subject phenomenon. For the eligibility of the study, the researcher chose only registered midwives or advanced midwives with more than one year in maternity unit. The size of the sample was considered satisfactory when data saturation was reached, implying that no new information was forthcoming during subsequent interviews. Data saturation was reached in 6th participant and the researcher stopped interviews immediately.
The researcher considered the rights of the participants. The interviewer established trust between himself and the participants respected them as autonomous beings, thus enabling them to make sound decisions. The following ethical principles were also employed:
· Signing of informed consent by participants;
· Ensuring confidentiality throughout the study process;
· Ensure anonymity and protection from harm;
· Participants were fully informed and knew that they could withdraw from the study at any stage without incurring negative consequences;
· Participants were informed that if emotional issues arise, participants would be referred to a professional counsellor;
· Audio-taped interviews would be destroyed once transcribed;
· Transcriptions were kept in a locked cupboard at the researcher’s home.
Data were gathered by means of semi structured phenomenological interviews. The interviews focused on the lived experiences of each participant with regard to caring of unbooked pregnant mother in maternity ward. The interviews gave the participants an opportunity to talk freely about their experience of caring unbooked pregnant women thereby giving the researcher an insight into their experience. As the interviews were semi structured, the participants and not the researcher controlled them. The researcher did not prepare a questionnaire as the questions arose from the participants’ descriptions of their experience.
“Explain in your views, how do you experience caring and managing unbooked pregnant woman in maternity ward?” Subsequent questions arose from the participants’ descriptions of their experience.
The interviewer created a context for the participants to speak freely and openly by utilising communication techniques such as clarification, paraphrasing, summarising, probing, and minimal verbal and non-verbal responses. The process was applied by the researcher to prevent the participants from feeling that they were being “cross-examined” on the topic. Participants’ permission was obtained to audio-tape interviews. Comprehensive and accurate description was achieved by adding handwritten notes to the verbatim transcribed accounts. During the interviews, the interviewer used bracketing (placing preconceived ideas aside) and intuiting (focusing on the lived experience of the participants regarding the caring of unbooked pregnant women). The researcher continued interviewing participants until data saturation was reached as demonstrated by repeated themes.
The researcher utilised a qualitative data analysis with rigour and care. Rigour in qualitative research refers to striving for excellence and is associated with discipline, scrupulous adherence and strict accuracy. All audio-recorded interviews were transcribed and transcripts were analysed manually using Interpretative Phenomenological Approach framework of analysis [
Transcripts were analysed one at a time through the stages stated in
Measures to ensure trustworthiness
Scientific rigor in qualitative studies, according to Grove, Gray & Burns [
Stage 1 | Reading and reading transcript to familiarize with participant’s account |
---|---|
Stage 2 | Making notes of interesting issues |
Stage 3 | Development of emergent themes that capture meaning of participant’s |
Stage 4 | Searching for connections across emergent themes |
Stage 5 | Development of a master table of themes containing subordinate themes, sub-themes and quotes from participants. |
Stage 6 | Development of a single master table of themes from master table of themes of individual transcripts. |
Identifier | Age group | Gender | Race/population group | Nursing category | Years of experience as a nurse (range) | Years of experience in the maternity unit (range) |
---|---|---|---|---|---|---|
P1 | 35 - 39 | Female | Black/African | Midwife (specialty) | 5 - 9 | 5 - 9 |
P2 | 25 - 29 | Female | Black/African | Midwife (General) | 10 - 14 | 0 - 4 |
P3 | 35 - 39 | Male | Black/Africa | Midwife (General) | 0 - 4 | 0 - 4 |
P4 | 45 - 49 | Female | Black/African | Midwife (specialty) | 0 - 4 | 5 - 9 |
P5 | 45 - 49 | Male | Black/African | Midwife (General) | 0 - 4 | 0 - 4 |
P6 | 50 - 59 | Female | Black/African | Midwife (General) | 5 - 9 | 5 - 9 |
described as the degree to which the identified meaning represents the perspectives of the participants precisely. Trustworthiness refers to validity and reliability or objectivity in research. Measures to ensure trustworthiness of the study evaluate whether the findings reflect the participants’ experience and not the researcher’s perceptions. The four criteria for establishing trustworthiness, namely: credibility, dependability, conformability and transferability were applied in the study. However, Activities in achieving credibility were prolonged engagement in the field, keeping reflexive journals, the researcher’s authority, peer reviews and structural coherence. Transferability was achieved through dense description of the data and purposive sampling. Dependability was achieved by a description of the method of data gathering, data analysis and interpretation. Confirmability was achieved by ensuring auditing of the entire research process and reflexive analysis.
This section presents the characteristics of the participants based on their age, ethnic groups, race, their nursing categories, years of experiences as both nurse general and in a maternity unit as displayed in
Discussion was based on schematic condensation of data in the table, and highlighted by direct quotations from the participants and relevant literature.
· Experiences of midwives
Although, the lives of both pregnant women and unborn baby depend on highly skilled midwives and medical doctors. These professionals especially, the midwives experience multiple challenges like poor working conditions, lack of basic equipment and shortage of highly skilled professionals to manage pregnant mothers.
It has been observed that department of health struggles to fill all required vacancies as suggested in the health establishment [
Themes | Categories | Subthemes |
---|---|---|
· Experiences of midwives | - Emotional challenges - Shortage and incompetence of midwives | o Fear o Anxiety o Maternal incidences |
· Caring for unbooked pregnant women | - Inexperienced midwives | o Lack of debriefing. |
· Support system | - Lack of support from managers |
situation compromises the expected quality of care provision especially in the maternal health facilities resulting in many incidences from shortage and litigations [
However, experiences of midwives are a main theme with two categories and two subthemes as determined in
- Emotional challenges
According to care search last updated (i.e. 14th February 2017), it is normal to have changing feelings and emotions especially when there is a serious event or incidence that cause reaction. It was further stated that a person changes feelings because of existing external stimuli at the time [
o Anxiety
The majority of participants reported that they were anxious. Their anxiety was related to the fact that most of them are new in the unit and have no experience in maternity unit. One participant expressed her feeling as follow:
“It is so scary to manage a Head On Perineum (HOP) as new midwives... and I felt uncomfortable having to deliver a baby sometimes no chance to wear protective gloves in an unknown HIV status woman”. PN1
Consistently, the abovementioned situation was similar with a study by Roets, Poggenpoel & Myburgh [
o Fear
The majority of participants reported the complexity situation that they found themselves in and with no point to escape. Some unbooked pregnant mothers’ delivery in the entrance and passages of the ward. Most reported that they even felt homesick. One participant was quoted as follow:
“I was so fearful of any emergency of unbooked mothers because of their complications followed by litigations... It was so difficult, what made me so fearful, was the fact that others made funny noise and sounds like animals, calling a nurse. Although I know they are just human beings like us but their behaviours differ completely from ours when they are in labour pains.” PN3
According to Uys and Middleton [
· Shortage and incompetence of midwives
Shortage and incompetency of midwives is a category under the main theme: experiences of midwives. Participants reported that there is a high rate of resignations and these resignations include skilled professionals like advanced midwives. Their shortage led to many specialised skills not performed. Some of the deaths are due to lack of advanced skills in performing certain procedures. One participant expressed her feeling as follow:
“I cannot deliver an obstructed or other complicated labour because I am not an advanced midwife... Sometimes unbooked cases come in numbers and with the current huge shortage of human resources and equipment and expected to ensure no deaths; this is a really frustrating situation”. PN4
A study by Mosehle, Matlala, Thanyani & Lumadi [
o Maternal incidences
Maternal incidence is a subtheme under the categorical theme: shortage and incompetency of midwives. Maternal incidences may either be necessary or unnecessary depending to the nature of its occurrence [
On the other side, unnecessary incidences in this study are those incidences that occur because of the failure of the professionals to organise their activities for helping the women to deliver efficiently. On investigation, the findings revealed a failure on the side of the practitioners or hospital setting. These incidences emanate from human error or mistake despite available resources to help during management of unbooked pregnant women [
In this study, participants reported that shortage of midwives and their incompetency are the leading causes of maternal incidences. They further stated that these poor outcomes result in litigations under maternal health services. One participant expressed her feelings as follow:
“Eeh I remember one day I was alone in labour ward assisting a patient who was giving birth and another patient came whilst I was busy with the first one, and deliver his baby without my assistance and the woman had an MSB”. PN5
Plenty of literatures revealed that many maternal incidences are being caused by huge shortage of midwives to manage maternity unit effectively [
· Caring for unbooked pregnant mothers
In details, care refers to those assistive, supportive, helping, facilitated, professional, moral and culturally accepted actions rendered to the individual, family or group, whilst feeling concern or interest, providing protection and showing attention to the one being cared for; through a competent and interactive therapeutic caring relationship [
Managing an unbooked pregnant case became a challenge in rural district hospitals because most of the midwives are not experienced and advanced in the maternity unit. Their biggest challenge is that they cannot manage working under pressure with inadequate resources and their incompetence to manage an emergency pregnant woman. Some studies around South Africa declared that rural district hospitals do not have a stationed doctor for maternity ward [
Indeed, unbooked pregnant mothers presenting in labour is common phenomenon amongst the study population, and might contributing to a significantly to the high maternal mortality rate in developing countries. Multiple efforts to ensure utilisation of antenatal services were done and still in considerations. It also revealed that caring for these types of patients require both enough basic equipment and human resources. This would minimise some complications [
- Inexperienced midwives
However, incompetencies of midwives were a category from the main theme: caring for unbooked pregnant women. Participants reported that there were many experienced midwives who had resigned for various reasons between 2015 and 2017 respectively. The current nurse midwives are inexperienced staff in maternity unit. These participants expressed their feeling of uncomfortable in performing certain procedures because they do not have many work experiences and feel incompetency in some extent.
- Lack of debriefing
Despite the poor working conditions and other unbearable circumstances they encounter, the debriefing session is lacking which would provide some corrections and counselling where necessary. One participant was quoted as follow:
“You know Sir, this institution does not have any form of debriefing after any session of incidence, although some of us are aware of debriefing from our previous employers but staffs here cite that they are busy with other duties.” PN6
Debriefing means a discussion that is held after an incident session which all aspect of events is deliberated and analysis is made. Debriefing after an actual critical event is an established good practice in maternal health to support affected midwives. The debriefing performance in maternity unit is supposed to be promoted by maternity team including management and other necessary stakeholders like Ambulance personnel. The aim is to facilitate discussion of actions and thought processes, encourage reflection, and ultimately assimilate improved behaviors into practice [
· Support system
Support system is important for developing team building initiatives. Therefore, these groups cohesion strengthen coping skills. Nurses especially midwives need lots of support and time from supervisors. Effective communication between registered nurses and their managers could assist with developing coping mechanisms to support each other.
- Lack of support from managers
Lack of support from the managers was a category from the main theme support system. One participant expressed her problem as follow:
“As midwives we always face situations that can be very depressing, if a pregnant woman dies or if a baby dies.... The supervisors are not there for emotional support instead they want us to write an incidence report only.” PN1
The abovementioned findings of participants are consistent with one of the studies by Jones-Berry [
Support is a category of verbal communication is one of the God’s great gifts bestowed to human [
In this study, the experiences of midwives were centered on their practical issues that would enhance quality of care in the maternal health facilities. The majority of experiences of midwives were supported by findings from other literature searches conducted. All the literature sources used in this study were based on the experiences of midwives for caring unbooked pregnant mothers. The participants expressed a need for management to participate during debriefing sessions. Their belief was that their support in these sessions would motivate their professional conduct in the maternal health facilities.
The study was aimed at exploring the experiences of midwives in a maternity unit as these experiences are central to the provision of quality of care in the maternal health facilities. The study findings have also shown that the experiences of midwives in a maternity unit are for provision of physical comfort, psychological support and adequate staffing and basic equipment. The findings of this study confirm previous findings and contribute additional evidence that poor health outcomes on maternal health facilities are associated with various factors such as staff incompetence, inadequate resources, labor complications, and the majority of midwives are newly qualified practitioners and poor working conditions.
Based on the abovementioned information provided, the researcher recommends that there should be collaboration between hospitals and serving primary health care clinics including community leaders. The effectiveness of this plan would assist in minimising self-referrals and unattended antenatal clients by clinics. The researcher also recommended that staff coverage should be considered including the employment of high skilled professionals. Lastly, the researcher recommends that some in-service trainings on the gaps identified would be conducted to minimise unnecessary adverse events.
One of the limitations of the study was that the study utilised small sample size of 10 participants. The information gathering was guided by data saturation in 6th participant. The study was conducted only in public hospital in Libode and did not represent the majority of the country context.
The author expresses his warmth thanks to the midwives who participated in the study and the outside reviewers of this article until its approval for publication.
The author declares no conflicts of interest regarding the publication of this paper.
Magqadiyane, S. (2020) Experiences of Midwives for Caring Unbooked Pregnant Mothers in a Maternity Unit at a District Hospital in the Eastern Cape Province. Advances in Reproductive Sciences, 8, 186-200. https://doi.org/10.4236/arsci.2020.84016