MATERIALS AND METHODS

Study design: A semi-experimental study (pre-test and post-test) research was used as a convenient sample of 25 midwives (available total number) were observed during the process of birth (from early-stage until the third stage of the birth process) by using an observational checklist after consent was obtained. None of the midwives refused to participate in the study as the head nurse advice all of them to participate and to take the training. Later, a standardized simulation training focusing on the role of midwives in reducing the Perineal trauma through the use of effective communication skills during the process of childbirth was given to the same midwives. After the training, a second observation was conducted for each midwife by the researcher to check for the differences in midwives behaviour, attitudes and Perineal trauma cases. The study took place from March-July, 2019.

Study tool: A semi-structured observational guide (adopted from Maputle²⁴) was used to observe each of the midwives’ communication aspects with women during delivery, informational support and health education provided, emotional support activities and supportive care activities during the childbirth process. A pre-test was conducted on three Saudi midwifery students to check for the need for any modification. The too was clear and suitable and no further modifications were applied.

The Female Nursing Institute prepared a training booklet for the midwives then it was approved by each of the Nursing and Midwifery Continuing Education departments in the hospital, the Academic Affair and then it was accredited by the hospital Quality Assurance department. The training booklet contains the objectives of each session and the main training contents, Fig. 1 shows the detailed training content. It is also worth adding that important language (Arabic) words that are necessary for the midwives to clarify the process of birth were added to the training, such as the Arabic words of pushing, taking a breath etc. The booklet was pretested on a special training conducted for midwifery high diploma students, to check if there is a need for any modification in each of the contents and tools of training, where we found the booklet to be clear and no further modifications were needed. The training was conducted in a high participatory manner, using simulation techniques for the process of birth and role-play for three consecutive days, 5 hrs a day.

Settings: The study took place at the King Faisal Armed Forces Hospital in the Southern Region of Saudi Arabia (KFAFHSR) in the Labour and Delivery Ward (L and D). This hospital was chosen because it receives patients from the whole southern region of Saudi Arabia, with high-quality standards facilities and staff accredited by The Joint Commission International (JCI) and The Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI). The L and D ward, on average has 150 daily deliveries and 360 daily visits to the antenatal clinic.

Statistical analysis: The statistical analysis of data was done by using SPSS statistical package for social science version 22 (Armonk, NY: IBM Corp). The description of the data was done in form of Mean±SD for quantitative data, where frequency and proportion were used for qualitative data. The analysis of the data was done to test statistically significant differences between groups. For quantitative data, independent sample tests were used, cross-tabulation and CHI SQUARE test was used for the quantitative variable, P is significant if <0.05 at 95% confidence interval.

Participants
Sample: Convenient sample includes the available number of midwives (25 midwives) from different nationalities and educational backgrounds. The majority were South African midwives ( n = 14) holding a midwifery diploma certificate.

Ethical consideration: The Research Ethical Committee at the Armed Forces Hospital in the Southern Region, before the research being conducted, approved the study (Code number: AFHSREC/2019/FEMALE NURSING INSTITUTES/340. Dated March 26, 2019). Furthermore, all midwives who participated in the study gave their consent, which included the purpose of the study and ensured anonymity and privacy. The Women also consented to accept the presence of the researcher during the birth process as well as to participate in the study.

RESULTS

Sociodemographic characteristics of the midwives: The data in Table 1 shows that more than half of the midwives were South African and 24% were Malaysian. Two third of them were certified as midwifery diplomas based on South African and Malaysian midwifery educational programs, 28% hold advanced midwifery diplomas and the majority had more than ten years of experience. However, the hospital employment requirement rule for midwives is to have a minimum experience of 3 years.

Communication, empowerment, advocacy and respect values: The data in Table 2 shows significant changes in midwives communication regarding woman empowerment after training, particularly in allowing the mother to make suggestions regarding her care and in discussing any advice given to the mother (p = 0.000 for both). Midwives also showed a significant improvement in terms of enabling the woman to feel comfortable and relaxed, particularly by communicating in an appropriate language (p = 0.000). The data in Table 2 shows that there is little improvement regarding the advocacy behaviour of midwives after training. On the other hand, the vaginal examination is done only when necessary showed significant improvement (p = 0.000). The data in Table 3 presents data regarding midwives respecting cultural and religious needs for the women during birth which was significantly improved after the training, particularly allowing women to drink herbs that are culturally accepted when necessary and not contradicted with women’s health or birth progress. In addition, there was some improvement regarding keeping women well informed during birth in terms of the mother’s health condition and the fetus’s condition.

Health education provided for women: The data in Table 4 shows the health education needs and the steps to providing health education during the stages of birth. The result shows that answering women’s questions and concerns during birth were significantly improved (p = 0.001). Additionally, necessary health education during the first stage of birth was also significantly improved. Health education necessary for the second stage of birth was also significantly improved. For example, teaching the mother the proper way of breathing between contraction, encouraging the women to bear down and discussing with the women the indication for Episiotomy (p = 0.001, 0.001, 0.000, respectively).

Health education during the second stage showed a significant relationship with the number of Episiotomy cases as it decreased from 11-5 cases post-training out of 25 women. In addition, health education had a significant improvement in regards to the first and second-degree tears as the number of women with first-degree tears decreased from 18-12 cases. Additionally, none of the observed cases had second-degree tear post-training compared to three cases pre-training when given incomplete health education that is missing three points or more (Table 5). Health education during the third stage of childbirth was not effective before the training but it did show little improvement post-training as only seven midwives have changed their behavior.

Supportive activities during birth: Emotional support was significantly improved post-training as almost all midwives were given proper emotional support during childbirth (Table 4). Post-training, only one observed midwife gave gentle massage for the lower back to relieve the pain. Additionally, one midwife provided warm compresses and gentle massage to the Perineal area post-training. However, there was a significant increase in encouraging women to urinate every 2 hrs (Table 4).

Perineal trauma and assessment: The results show that there were significant changes in using effective communication and activities necessary to reduce Perineal trauma, particularly in providing proper position, Episiotomy well-informed and injections of lidocaine. However, cutting Episiotomy in the right timing did not show a big difference before and after training as still half of the midwives did not follow the training recommendations (Table 5).

Overall, trauma and Episiotomy was decreased post-training and was also decreased by most midwives (from 56% of midwives to 80%). The degree of trauma was also decreased, especially the second degree, which was minimized to 0%, whereas half of the observed deliveries resulted in no trauma at all. In terms of bleeding during birth, it was significantly decreased post-training. Suture line average length was also decreased from 3.88-1.62 cm. Post-training, pain scale measurement was reported to be decreased as well (Table 5).

DISCUSSION

The study gives a clear idea that in general, midwives were lacking effective communication skills with women during the process of birth. However, this problem was relatively corrected after training as the midwives in the present study showed some improvement. Effective communication between midwives and women during childbirth with evidence in improving the health outcomes and a healthy birth as well as improving patient's satisfaction²⁵. Katebi et al.²⁶, who conducted their study in Iran, has focused on the importance of proper midwives-women communication in increasing women’s mental health level and developing better birth outcomes.

Looking to the fact that midwives have a different educational background, coming from different cultural perspectives, in addition to having language limitations, midwives might have difficulty in communication using proper messages with the women during birth^27-28. This study shows that, after training, midwives had improved their language explanation when talking to the women using appropriate wording. They also showed significant improvement regarding giving the women opportunities to participate effectively in the birth process by allowing them to give suggestions or express their thoughts. This put the women in a role of participatory rather than the recipient of the health care. Overall, when the woman knew that they are a part of the care provided to them and allowed to express their feelings, their opportunity to learn and to cooperate during the stage of bearing down will be more effective and their pain distraction will be focused on her health matter rather than on the pain itself ²⁹. Wiech and Tracey³⁰ discussed that the pain process could be highly influenced when women are engaged in the process of health care. Manary et al.³⁰ discussed the positive correlation of a patient’s engagement in their health care and their overall health outcomes²⁹.

In this study, training caused an effective improvement in midwives’ level of communication as well as in delivering proper health education. The same effect was also shown in a study that was conducted in Iran³¹ where similar training was also conducted and they found similar results. In their semi-experimental study, a two-session training workshop was organized for 40 midwives regarding communication skills that enhance women’s satisfaction during childbirth. Later, women satisfaction were tested before and after the training and they found that mothers’ satisfaction had significantly increased post-training (p = 0.003), whereas, midwives’ communication level and behaviour was also significantly improved post-training (p = 0.002). Continuous training for midwives can increase women’s satisfaction from the childbirth process as well as improve health outcomes³¹.

We found that there was an improvement regarding Perineal tear caused by midwives’ training and communication skills development as the Perineal tear was significantly decreased. After training, 52% of women had no type of trauma compared to only 36% before training. Several communication measures showed significant improvement after training, such as informed health education during the stages of birth, as well as informing the women regarding the need and the process of Episiotomy. Women were also well informed regarding the process of birth, exact timing to bear down and the strategies to facilitate the process of birth. This communication level and process were recommended by the WHO³². Lindgren³³ suggested as well that effective communication between midwives and women could help in decreasing genital tears and trauma. Health education after the training of midwives showed significant changes as providing essential health education for midwives, especially for the first and the second stage of childbirth influenced decreasing the Perineal trauma and women’s bleeding and pain. Health education mainly focused on the breathing exercise in the first stage and on the timing to bear down in the second stage. Lemos et al.³⁴ have concluded in their review study that there is no clear effect of timing nor the duration of pushing on reducing Perineal laceration. On the other hand, Dieb et al.³⁵ in a very recent study found that health education during the process of birth, as well as antenatal education, could help in reducing Perineal complications for women above the age of 35.

Episiotomy in some hospitals is routine management for women experiencing first childbirth as one study in Saudi Arabia have found that half of the women had to go through Episiotomy³. However, Episiotomy could increase postpartum morbidity in terms of postpartum pain and discomfort as well as maternal mortality. Therefore, Gün et al.³⁶ in their meta-analysis study suggested restrictive rather than routine Episiotomy. In the present study, we found that the number of episiotomies was decreased after the training and the reason might be that midwives did not find it very urgent and might have delayed the Episiotomy to adopt other measures such as massaging, supporting the premium, proper pushing, communication with the woman and providing a relaxing environment. Although the hospital where our study was conducted as a routine measurement of Episiotomy for all women experiencing their first birth, midwives still worked hard to advocate for the women in that matter. However, some midwives did not follow the training recommendations since they felt that might be less confrontational with the hospital policy. The result of this was less Perineal trauma and fewer complications. This goes with the WHO Episiotomy recommendations³².

Massaging the lower back to relieve the pain wasn’t done properly even post-training. Therefore, this issue was discussed individually with the midwives and we found that they refrain from doing it because they might offend the cultural privacy of the Saudi women and this action might not be socially accepted. A similar explanation was also noted in one review study by Alshammari and Guilhermino²³. To the use of Perineal warm-compresses, only one midwife had done that post-training. It was found that midwives were not convinced about its effect on reducing Perineal trauma. When it was discussed with the midwives, most of them said that they did not have it in their curriculum study of midwifery. However, many recent studies showed a great effect of warm-compress on maintaining the intact of the perineum and reducing the need for Episiotomy^37-38.

Poor communication and ineffective methods of verbal and nonverbal communication among midwives and mothers during childbirth have been observed in several other studies regardless of the midwives’ backgrounds, being from different nationalities or having a language barrier^23-39. The same problem was found in this study as the majority of midwives had a problem in communication before the training but later after the training, midwives had improved their communication levels such as focusing on more effective and goal-directed communication and health education. Therefore, communication skills need to be enhanced in the midwifery programs as well as in the continuous assessment and in-service training.

This study faced some limitations, for example, after the training, the midwives might be influenced by social desirability bias as to please the researcher following training rather than a real change in behaviour or attitude. The language barrier and cultural diversity of midwives were also concerns during the training and communication with women. Effective communication between midwives and women during normal childbirth as well as the advocacy role in using Episiotomy only when necessary rather than following it as a routine activity should be encouraged through midwifery teaching programs and curriculum. Future studies by taking different study groups are recommended which might help in further understanding of the influence of communication and women involvement in decreasing Perineal trauma.

CONCLUSION

Effective communication, using appropriate language and informative health education during the process of childbirth might decrease Perineal trauma. Midwives advocacy role and calling for Episiotomy when necessary can decrease the long term effect of Perineal trauma and morbidity. Women’s participation in the process of delivery through effective health information and education could decrease Perineal trauma and might decrease the level of pain during normal childbirth.

SIGNIFICANCE STATEMENT

This study explores the importance of Empowerment of women during childbirth by midwives can minimize Episiotomy needs. In addition to the importance of direct communication between midwives and women with relation to the process of delivery could play a role in decreasing Perineal trauma and pain. Moreover, midwives usage of standardized communication (health education) with women during birth could help women to be more involved, cooperative and decisive. This modifying communication strategy of midwives would among other measures help in improving the overall women health outcomes.

ACKNOWLEDGMENTS

The authors thanks the general staff, midwives and the midwife-in-charge for the labour and delivery ward. The dean of the Female Nursing Institute and the head of the midwifery program for their help in preparing the training manual and conducting the training. We also would like to thank the hospital ethical committee, academic affairs and quality department for their valuable review of the study tool and the training manual.