Expectations and Experiences of Women in Pregnancy,Childbirth,and Infant Feeding: A Qualitative Research Protocol

Pregnancy

Throughout pregnancy, women may encounter a variety of situations, ranging from physical to emotional, which affect both the mother’s and baby’s health (Beales et al., 2016; Ziomkiewicz et al., 2019). Thus, needs and concerns arise related to their bodily sensations, changes in lifestyle and fears about the possibility of miscarriage (Lou et al., 2017). In the psychological field, women’s evaluation of body image affects their self-concept and self-esteem, which appears to be related to perinatal and postnatal depression (Silveira et al., 2015). Their lack of knowledge about their fears or the proximity of childbirth and the care of the baby requires professional and emotional support that provides appropriate information (Lou et al., 2017; Paz Pascual et al., 2016).

Our cultural perspective influences the way we understand and consider the biological concept of pregnancy (Russo, 1979). In many cases, the medicalization produced by the increasing use of technology to avoid possible risks turns the process of motherhood into a pathological-like process, in which the mother is a mere “vessel” (Davis-Floyd, 1994; Fairchild, 2017; Foucault, 1990). However, as Foucault (Foucault, 1990) says, “neither for the subject nor for the physician does it constitute a disease.” In this way, the medical system prioritizes scientific knowledge, relegating the perceptions of pregnant women to a second place. This medicalization reduces the mother’s involvement in decision-making about the course of her pregnancy.

It is essential for pregnant women to be an active part of the process and feel they have greater control over it (Borrelli et al., 2018; M. Hollander et al., 2019). Currently, the World Health Organization (WHO) recommends continued care during motherhood, which should be directed by professionals from different disciplines, and advocates for models of antenatal care directed by midwives. This approach helps women to adjust their expectations and develop care skills, with the ultimate goal of offering women humanized care that provides psychosocial and emotional support through the use of effective and appropriate practices (WHO, 2016).

Birth

The moment of birth gives rise to concerns that will be influenced by the mother´s knowledge and expectations. One of the most common feelings found among pregnant women concerning childbirth is fear. This increases the perception of childbirth as a traumatic and painful process (M. H. Hollander et al., 2017) and may be enhanced by false beliefs or negative experiences, generating a state of anxiety linked to possible complications (e.g., cesarean section; Robson et al., 2017). Several studies show how expectations, linked to false myths and fear, influence the decision of whether to have a natural birth. Thus, younger women with less confidence in their knowledge, which is often acquired in an informal environment, are those who tend to prefer a medicalized childbirth (Larsson et al., 2017; Swift et al., 2017). There is a continuum between natural and medicalized birth along which women are placed according to their preferences (Benyamini et al., 2017). Nurses and midwives, through health education, can empower women to make decisions about their pregnancy and type of birth (Borrelli et al., 2018; Paz Pascual et al., 2016).

Acquisition of accurate and realistic knowledge of the process of birth is valued positively by women. Therefore, they need a suitable professional to help them decide a birth plan and the different alternatives, following appropriate guidelines (Borrelli et al., 2018; Van der Garde et al., 2019). Several articles have shown that both the lack of control and communication and the support to face difficulties are related to the experience of a traumatic birth (Borrelli et al., 2018; M. H. Hollander et al., 2017). Taking into account the beliefs and expectations of women and their perception of the health care received could help humanize childbirth (Larsson et al., 2017).

The prevalence of the technocratic paradigm, which explains the unneeded application of technology in the control of natural processes, bolsters the medicalization of childbirth (Davis-Floyd, 1994). In this way, the mother is distanced from the process, being treated as a passive subject, and having her preferences in an intimate and personal process neglected (Davis-Floyd & Sargent, 1996; Jones, 2012). In addition, the high level of medicalization has been associated with a decrease in night births, which are believed to form part of an evolutionary adaptive pattern based on a maternal circadian mechanism, affecting mother-child relationships, breastfeeding, and postnatal health (Bernis & Varea, 2012). Focusing on the medical perspective can accentuate the gap between the experience lived and the expectations of the mother so that they feel disconnected from the process of birth as well as making decisions about this (Jones, 2012).

Infant Feeding

Infant feeding encompasses different feeding models in which breastfeeding is considered the most beneficial from a health perspective. The benefits of breastfeeding are highly documented among the scientific community (Chowdhury et al., 2015). The composition of breast milk adequately provides the nutrients that the infant needs for its development, as well as micronutrients and other bioactive components that are associated with both short- and long-term benefits (e.g., immune system, cognitive disorders). Thus, breast milk improves the baby’s immune system such that prolonged breastfeeding over time prevents conditions such as asthma, atopic dermatitis, or eczema. It also provides benefits to the mother, such as reduced risk of breast and ovarian cancer (Salone et al., 2013). The WHO recommendations advocate exclusive breastfeeding for the first six months and supplementary maintenance for up to 2 years minimum (United Nations International Children’s Emergency Fund [UNICEF] & WHO, 2017). However, dropout rates are higher than desirable, and despite the data for exclusive breastfeeding having increased in recent years, they are still far from these recommendations (Victora et al., 2016). In addition, formula milk is being increasingly improved and developed, and there are specific ones adapted to the needs of the newborn (Milbrandt, 2017). The aspects involved in the mothers’ choices of the type of food they give their children are not only related to maternal and child health reasons (Takahashi et al., 2017), but social aspects also have an impact on the decisions that mothers make (Colodro-Conde et al., 2015).

Several factors are involved in the cessation of exclusive breastfeeding in high-income countries, such as maternal and child health conditions (due to possible complications such as mastitis, cracked nipples, or low weight gain), factors related to the mother’s environment, such as her insertion in the labor market (Kleven et al., 2019; Odom et al., 2013), or the social expectations of the role of “good mother” (Colodro-Conde et al., 2015; Russo, 1976). Therefore, mothers face changes with implications for their physical and mental health, as well as their work and social status (Morris et al., 2019; Verniers & Vala, 2018). An inadequate approach that idealizes breastfeeding creates expectations far from reality and can become an element of added pressure (Slomian et al., 2017).

The decision to prolong breastfeeding increases the amount of time dedicated to the care of the baby, entailing an economic impact. What is commonly known as “child penalty” is an indicator that reports how the employment status of women in relation to men is affected by maternity. In different European countries, motherhood has been observed to have an impact on the position of women in the labor world, whereby they suffer a decrease in their income that fails to return to the level they had before the birth of the first child (Kleven et al., 2019). In this sense, prolonging exclusive breastfeeding has an opportunity cost for women. In high-income countries, it has been found that women with higher incomes and higher education continue to breastfeed longer (Victora et al., 2016), suggesting that an increased investment in family policies could reduce this opportunity cost, influencing their decision about their maternity and infant feeding (Kleven et al., 2019; Odom et al., 2013). However, there are differences in spending on family and children benefits, with high variability across Western European countries. In fact, in this regard, Spain invests around half of the European average (Eurostat, n.d.-a).

Therefore, attention to breastfeeding mothers could be improved if we had adequate information on their expectations and experiences. The support that can be generated by health professionals, especially nurses and midwives, is crucial for adequate management of infant feeding, avoiding early dropouts from exclusive breastfeeding (UNICEF & WHO, 2017).

Objectives

The aim of this study is to identify the beliefs and expectations that women have when considering their motherhood and what their experiences are when confronting the different stages of the process, including pregnancy, childbirth, and infant feeding. We will attempt to determine their perceptions of their self-efficacy in the management of both their own and their babies’ health in order to discover the social and health care needs that women perceive in the situations that arise during this process.

Methodology

This qualitative study follows a phenomenological perspective (Cypress, 2015). Our goal is to determine the expectations of women during their motherhood, and to this end, we deem the theoretical framework of Social Cognitive Theory to be the most appropriate approach (Bandura, 2001). This theory allows us to explain human behavior considering the influence of the social imaginary, the realities found, and the social and personal expectations. These three factors participate in the development of the self-concept, decision making, and conflict resolution styles that we implement, allowing us to delve into the aspects of the different social and personal agencies of learning, self-concept, and self-efficacy.

Beyond this, the social cognitive theory of the development and functioning of the role of gender is the ideal substrate to observe and understand motherhood and the processes that surround it. These are conditioned by gender-regulated behaviors through social sanctions and self-sanctions, as well as by perceptions of self-efficacy learned through experience and models observed during development (Bussey & Bandura, 1999). Therefore, it is pertinent to approach our research focusing on gender, which explains the perspectives internalized by women as a result of having lived in a particular environment and with a specific social and cultural history.

In order to meet the objectives, a semi-structured interview was considered the best way to collect information. It is common the use of interviews in health research to obtain empirical data that inform us about people’s experiences. The semi-structured interview helps us to understand people’s attitudes about certain processes, and how we can provide them with the necessary health support, or how we can improve the care supplied. Thus, a qualitative design with a thematic analysis approach is considered the appropriate methodology for the development of our research (Braun & Clarke, 2006).

Data collecting

In order to carry out the semi-structured interviews, a preliminary script has been prepared to determine the most important aspects into which we wish to delve deeper, based on the previous documentation work. The script focuses on three main blocks shown in Figure 1: i) Maternity, ii) Pregnancy, Childbirth, and Postpartum and iii) Infant feeding. We used a field-testing technique to verify the coverage and pertinence of the subject matter of the script and check its implementation (Robinson, 2014). In this sense, we carried out two pilot interviews at a meeting point in the research center.

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Figure 1.

Script of interviews.

The interview, which takes 45–60 min, will be carried out face to face, establishing a bond between the researcher and the respondent that helps create a climate of trust. All interviews will be recorded for later transcription and analysis. All this process allows us to assess the aspects that have proven significant in the prior documentation work while it also facilitates the women’s free expression of their expectations and experiences (Mitchell, 2015).

The interviews will end with the sampling saturation criterion, after which the recordings will be transcribed using the F4 software tool. A summary of the main ideas found will be given to the participants for them to give their consent.

Ethical Aspects

This study has the approval of the Clinical Research Ethics Committee of Virgen de la Luz Hospital (Cuenca, Spain), obtained for the MOVI-da 10! intervention, of which it forms part (approval number: 2008PI0708). Participants will be informed of the estimated duration of the interview, and to ensure the rights of patients regarding confidentiality, they will be informed at the beginning of the interview that it is being recorded. Therefore, for anonymous treatment of the data, we will advise them of the assignment of an identification code that will allow their identity to be disassociated from the content of the interview. Likewise, they will be reminded that they can revoke their consent at any point of the research process.

Validity and Rigor

In order to ensure a rigorous analytical approach, several strategies will be used. The sampling technique used will improve the reliability and credibility of the possible findings. This technique will enable us to access a heterogeneous population (i.e. rural and urban environment, different socioeconomic level, migrant or not), but with a shared cultural reality (pregnant women in Western society).

The interviews will be conducted in pleasant, private environments that allow women to express themselves freely. The validity will be reinforced by the systematic use of semi-structured interview techniques performed, in all sessions, by the same researcher. The interviewer will have ample experience in qualitative methodology and communication skills (Mitchell, 2015).

In addition, a summary of the information obtained will be sent back to the women to be checked. After this, the data will be analyzed by three different researchers at three levels of depth (Giacomini & Cook, 2000). This analytical strategy will permit the subsequent discussion of possible discrepancies and their resolution by consensus.

Discussion

We will carry out a qualitative study within a phenomenological perspective by means of semi-structured interviews with the subsequent analysis of the information using a thematic approach. It should be considered that a study of these characteristics is favored by the qualitative approach of the investigation, in such a way that this methodology will provide us with a secure scientific framework that supports our findings and helps us to sustain the social and health care offered to mothers based on scientific evidence.

Conclusion

The medicalization of care removes women from the center of a process in which they are an essential part. Nurses and midwives can provide support, information, and care that helps the mothers to obtain the best health status for them and their babies. We must, therefore, include women as a central part of the process to improve care so that they are an active part of it, and we can offer advice, support, and quality care with the guarantee of expert knowledge based on the best available evidence.

The complexity of the maternity process from a biopsychosocial perspective and its influence on low birth rates, contributes to population aging in the countries of Western society. It seems necessary to investigate in depth the particular perceptions of women regarding their motherhood and to focus this research from a gender perspective that puts women back at center stage. In this way, we can assess the quality of the assistance received in their social and health needs and identify the aspects that can influence their decision to have further offspring.