Mothers' and healthcare stakeholders' views and experiences of birthing postions and perineal injuries during childbirth in a low resource setting in Nigeria.

Background. Cumulative evidence supports the use of upright positions during labour and childbirth, which has benefits for both mothers and babies. Despite strong evidence supporting upright birthing positions, semi-recumbent or lithotomy positions for birth continue to be the most commonly used in some part of Nigeria. Also, it has been reported that episiotomy is commonly practised in some regions. The high rate of episiotomies performed in Nigeria, and the lack of adoption of guidelines in respect to the restrictive use of episiotomy, has contributed to a continued rise in surgically induced perineal trauma. The aim of this study was to explore the views and experiences of mothers, midwives and obstetricians in Nigeria regarding the use of upright position during birth and the perineal outcomes.
Methods. The study utilised a mixed-methods approach and was conducted in two phases. Phase 1 utilised a questionnaire survey and descriptive statistics. The questionnaire was administered to 110 mothers and 110 midwives in two tertiary hospitals in Nigeria to explore the prevalence rate of different birthing positions and the views of mothers and midwives regarding the birthing position and perineal injuries during childbirth. The questionnaires were pilot-tested with 10 postnatal women and 10 midwives. Minor amendments were made to some word descriptors on both mothers’ and midwives’ questionnaires based on the feedback received. Data analysis was supported with SPSS Version 21. Frequency and percentage distributions were used. Phase 2 involved 12 mothers, 12 midwives and eight obstetricians who participated in qualitative interviews to
explore their views and experiences in more depth. Their experiences were collected as text and analysed using Braun and Clarke’s (2006) thematic analysis framework.
Findings. Phase 1 found that both mothers (n=94: 85%) and midwives (n=108: 98%) reported a semi-recumbent birthing position was predominantly used and was chosen by the midwives, not the mothers, during childbirth. Many mothers
(n=63: 57%) did not find the position helpful but some midwives did (n=65: 59%). However, a large majority of both mothers (n=106: 96%) and midwives (n=97: 88%) reported a willingness to try different birthing positions. Episiotomy was found to be predominantly used (n=80: 73%); most mothers (n=76: 69%) reported that it was performed without their consent,
and many (n=59: 54%) were not given any painkiller before its performance. A number of midwives confirmed that they performed an episiotomy without local anaesthesia (n=30: 27%). Phase 2 found that mothers were powerless and passive during their birth and at risk of an episiotomy being performed. Midwives and obstetricians accepted embedded birthing practices at the two study hospitals without questioning these practices or considering contemporary evidence. However, a willingness to change, adapt and incorporate clinical practices based on contemporary evidence that benefit women emerged
close to the completion of the study.
Conclusion. Findings provided some insight as to why the adoption of a semi-recumbent birthing position and the common use of episiotomy are standard practices, even though they are not supported by evidence. The collective findings gathered from mothers, midwives and obstetricians demonstrated a positive outcome in as much as, at the outset of this study, the use of a semi-recumbent position for birth and episiotomy was entrenched in clinical practices. However, participation in the study generated awareness of birthing practices that were not based on evidence, which were then reflected upon and are now
being challenged. A change process that involved critical thinking and recognition that clinical practice should be based on evidence is found to be occurring.