Midwifery 30 (2014) e79–e90

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Perinatal women's perceptions about midwifery led model of care in secondary care hospitals in Karachi, Pakistan Shahnaz Anwar, MScN, RN, RM (Instructor)n, Rafat Jan, PhD, RM (Associate Professor), Rahat Najam Qureshi, MBBS, FRCOG, FCPS (Associate Professor), Salma Rattani, MScN, BScN, RM (Assistant Professor) Aga Khan University Hospital and School of Nursing and Midwifery, Stadium Road, Karachi, Pakistan

art ic l e i nf o

a b s t r a c t

Article history: Received 14 March 2013 Received in revised form 14 October 2013 Accepted 22 October 2013

Objective: the purpose of this study was to explore the perceptions and experiences of perinatal women who have availed of midwifery led model of care (MLC) at secondary care settings in Karachi, Pakistan. Design: a qualitative descriptive exploratory approach using semi-structured interviews. Participants: a purposive sample of 10 women who had used MLC was enroled from each site. Findings: content analysis highlighted that ‘women's satisfaction with MLC’ emerged as the main theme and, under this theme, the six categories that emerged were: (1) the admired capability and maturity of midwives, (2) the affordability of midwifery services, (3) a personalised relationship, (4) the empowerment of women to make decisions, (5) presence, and (6) a voiced concern regarding lack of marketing of MLC. Key conclusions: the study findings revealed that women had an overall feeling of satisfaction with the maternity care provided by the midwives. Mostly, women appreciated the midwives' expertise in providing maternity care. Majority of the women acknowledged the continuous presence of the midwives during childbirth and the women shared that they were empowered to make decisions related to their care. Most of the women indicated that marketing for MLC is scarce and insufficient. Majority of the women are even not aware of this model; therefore, it is imperative to create awareness and to provide MLC access to women through robust marketing. Implications for practice: the findings of this study may help to advocate and provide women-friendly maternity care, by giving choice and control to women during childbirth, providing comfort to women by using fewer medical interventions, and promoting normality by attending spontaneous vaginal childbirths. & 2013 Elsevier Ltd. All rights reserved.

Keywords: Midwifery led care Women's perceptions/experiences Women's satisfaction with care

Introduction Globally, the maternal mortality ratio (MMR) is 400 maternal deaths per 100,000 live births (WHO, 2000). Preventable causes that lead to maternal deaths include antepartum and post partum haemorrhage, pre-eclampsia and eclampsia, obstructed labour, sepsis, and unsafe abortions; approximately 80% deaths occur due to these causes (WHO, 2012). In 2005, the MMR was 490 maternal deaths per 100,000 live births in South Asia (WHO, 2005). Approximately 16,500 maternal deaths occur every year in Pakistan (PDHS, 2008). According to the results from the demographic and health survey (DHS) 2006–2007, the MMR for Pakistan ranges from 276 to 700 maternal deaths per 100,000 live births (PDHS, 2008). By

n

Corresponding author. E-mail address: [email protected] (S. Anwar).

0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.10.020

comparison with other countries in the region, India accounts for 19% of the global maternal deaths; whereas, Bangladesh, Afghanistan, and Indonesia account for 3–5% of the global maternal deaths (WHO, UNICEF, UNFPA and The World Bank Estimates, 2010). In the South Asia, NMR estimates are 33 deaths per 1000 live births (UNICEF Regional Office for South Asia, 2008), and in Pakistan this ratio is estimated to be 41 deaths/1000 live births (UNICEF, WHO, The World Bank, the United Nations Population Division, 2011). Furthermore, as stated by the Pakistan Demographic Health Survey (PDHS) 2011 report, the total fertility rate (TFR) in Pakistan is 3.17; thus, it is higher as compared to the TFR of other developing countries in the region such as India, Sri Lanka, Nepal, and Bangladesh (Population Reference Bureau, 2011). These data indicate the demand and need for maternal and child health (MCH) services in Pakistan. Effective evidence-based maternity care with the least harm is optimal for childbearing women and newborns. A report by the Institute of Medicine of the United States (IOM) (2001) suggested

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that maternity care should pursue the standard of providing effective care with the least injury by supporting women's own natural capabilities to give birth physiologically. The implementation of the use of a woman-friendly model is most evident in the midwifery led model of care (MLC). MLC is very old and it varies from country to country (Feldhusen, 2000). In this womanfriendly model, midwives support and maximise the opportunity for normal birth and safe motherhood by providing accessible, affordable, and acceptable maternal and newborn care, which ultimately empowers women by respecting their rights to information, choice, and involvement in their own care (RCM, 2000). Hildingsson and Thomas (2007) claim that the use of MLC will help in decreasing maternal mortalities and morbidities because it aims to increase the utilisation of maternity services by a midwife who can provide safe quality care which leads to maternal satisfaction. It promotes normality by increasing the physiological capability of women to give birth with minimum or no interventions (Rooks, 1997). Moreover, MLC can be a significant maternal and child health care model as it focuses on women-centredness by being responsive to an individual woman's needs. It can enhance a client's satisfaction in the following ways: (a) a woman is given a choice and allowed to be personally involved in her own maternity care; (b) it enhances a woman's self-efficacy by making her realise that she is able to achieve her desired goal; and (c) a woman is provided competent, evidence-based, and cost-effective maternity care to improve her health and wellness (RCM, 2000). According to Zander and Chamberlain (1999), in many countries during the antenatal, intrapartum, and postnatal periods, a woman receives 75% of her care from a midwife. Women view midwives as their primary care providers during the maternity phase (Rooks, 1997). Women are satisfied with midwifery care and identify that care provided by midwives is client-centred and costeffective. Moreover, a woman chooses a midwife because she feels that midwives are reluctant to interfere with nature and, thus, they try to use their personal skills more than any technology (Walker, 2001). In addition, women are capable of giving birth by using their own power (self-efficacy), hence, pregnancy and childbirth are seen as common life events by midwives (Rooks, 1997). To manage childbirth effectively and to emphasise women's needs, different models of maternity care have been introduced in many developed countries (Heavey, 2010; Sandall et al., 2010). The important models of care other than MLC include a medical-led model, family doctor-provided care, and a shared-model of care (Hatem et al., 2008). In MLC, women identify a midwife as their lead health professional in the planning, organising, and delivering of care throughout the antepartum, intrapartum, and postpartum periods, and for the care of the newborn. The philosophy of care in MLC is seen holistically by women, because it acknowledges that psychosocial elements, such as the relationship between the woman and her family and her care provider are crucial components of physical and clinical maternal and child health (Rooks, 1999). During childbirth, a woman should be considered as the primary decision maker and she has the right to the information that enriches her decision-making capabilities (ICM, 2002). Moreover, as supported by Sandall et al. (2010), MLC can be considered as one of the leading childbirth models in the future for normalising and humanising childbirth for a woman. In the medical-led model of care, obstetricians are the primary care providers during different periods of childbirth; an obstetrician is present to attend to the woman, and nurses provide the postnatal care. In the family doctor-provided care, a medical doctor is present for attending to the birth and midwives provide intrapartum and postnatal care but they are not involved at the decision-making level. In the shared model, the organisation and delivery of the care of a woman, from the initial booking to the postnatal period, is shared between different health

professionals that include a midwife and/or an obstetrician (Hatem et al., 2008). In rearranging existing maternity services in order to introduce MLC, emphasis has to be placed on ensuring the availability of trained and knowledgeable midwives for providing maternity care to women. In many developed countries, autonomous trained midwives are responsible for providing maternity care to women during childbirth. On the contrary, in Pakistan, MLC is not popular due to a greater emphasis on the medical-led model. Moreover, in private and government health care facilities in Pakistan, MLC is provided by midwives who are trained and licensed by the Pakistan Nursing Council; in community settings maternity care is provided by the traditional birth attendants (TBAs), who do not have formal training (Jafarey et al., 2008). Maternity centres with midwives are often not popular because it is believed that midwives lack necessary knowledge and competencies. Hence, women are often not encouraged to go to those centres where services are provided specifically by midwives. It is believed that the midwifery training centres in Pakistan do not prepare midwives to be autonomous health care providers because of their short study duration: 15 months for pupil midwives (direct entry program), 12 months for nurse midwives (postlicensure), and 18 months for community midwifery training (Jafarey et al., 2008). However, according to the Pakistan Nursing Council (PNC) midwifery curriculum (2005), it is obligatory for a midwife to be able to take a comprehensive history and perform physical examination according to a mother's condition, and conduct normal births and refer women with complications to the obstetrician. Therefore, successful MLC is available in Pakistan to women from trained midwives who are expert in conducting normal childbirth and in detecting and appropriately referring deviations from the normal. Midwifery training is provided in many secondary and tertiary care hospitals in Karachi. In one of the tertiary care hospitals, four secondary sites were merged in 2009 for an improvement in maternal and child health service provisions. To reinforce midwifery care practices, at present, MLC has been introduced in only two sites to fulfil the above mentioned objectives. In these secondary care units, MLC is available along with the medicalled models. Both quantitative and descriptive exploratory qualitative studies have been done in different countries focusing on client satisfaction with respect to continuity of care by midwives, midwives' competency, cost-effectiveness of MLC, satisfaction with choice, control, and presence of the midwife. These have been done in relation to women's perceptions and experiences with MLC. In Pakistan, MLC has been less active in the past few years due to the emphasis on the obstetric model of care. A review of the literature indicated a significant gap with regard to the use of MLC and women's experiences in the Pakistani context i.e. Jafarey et al. (2008). Hence, it was felt that further research was needed to explore the perceptions and experiences of the Pakistani women who had utilised MLC. This study was undertaken to explore MLC at two sites, to explore women's experiences and perceptions about MLC. The purpose of the study was to explore the experiences and perceptions of Pakistani perinatal women who had used MLC during the antenatal, intrapartum, and postnatal periods at the secondary care settings. This study also aimed to identify the advantages and disadvantages, and the challenges of using MLC.

Methods For this study, qualitative descriptive exploratory research design was used. As perceptions and experiences varied from woman to

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woman, this study design helped to collect rich data. Ethical approval was obtained from the Ethical Review Committee of the University which reviews details regarding ethical matters such as maintaining anonymity, autonomy, and confidentiality of the participants; these were subsequently submitted and approved. The study population included women who had used MLC during the antenatal, intrapartum, and postnatal periods at the secondary sites. Both these hospitals are each a 48-bedded unit and are fully equipped with a delivery room, operation theatre, laboratory, pharmacy, nursery with incubators, and paediatric wards. The hospital services also include out-patient clinics in obstetrics, gynaecology, paediatrics, family planning and infertility, and general surgery. Both these sites have midwifery schools that offer a diploma in midwifery with 12, 15 and 18 months' programs. To recruit participants for the study, written permission was obtained from the manager of the midwifery and nursing services of the secondary sites. After obtaining the permission, the researcher worked with the midwives and reviewed the hospital records to contact women who had used MLC. The invitation letter for participating in the study was given to potential participants who were aged between 25 and33 years, had no medical and obstetrical complications, and who agreed and volunteered to participate in the study. Participants who had complications were excluded; and those participants who did not give consent were not made a part of the study. A purposive sample of 10 women who had experienced MLC was enroled in the study after taking voluntary written consent. Among these 10 participants, five women were from each site. Women who visited the hospital during the months of April to June were made part of the study. After the registration of the women, the date and time to plan the interview process were discussed. A semi-structured interview guide was used as the data collection tool. Prior to conducting interviews, pilot testing of the interview guide was done in which two women who had given consent and had participated in MLC were selected from each site. Pilot testing helped in finding out whether the participants were comfortable with the interview guide or they faced any problem (Polit and Beck, 2008). In addition, probing questions were also used to explore the phenomena of enquiry. Data collection was done from April to June 2012. The demographic profile of the study participants was obtained at the time of recruitment of the participants; this was later confirmed by the participants before beginning the interview. Because the participants were fluent in Urdu, the researcher conducted the interviews in the Urdu language by using an interview guide that was translated in Urdu. Each interview lasted from 30 to 90 minutes, and was audio recorded for analysis purposes. As part of the data collection process, the researcher took field notes about the participants' non-verbal expressions during the interviews. Moreover, reflections were written by the researcher to minimise researcher bias. Data analysis was done manually, simultaneously with data collection (Streubert-Speziale, 2006; Polit and Beck, 2008). Interpretation of the transcripts was done by using the steps of content analysis as described by Creswell (2003). Initially, data were organised and prepared for analysis by creating a separate binder and electronic folder which comprised the demographic profile of the study participants, field notes, and researcher's reflections. The data were transcribed verbatim in Urdu initially and later translated into the English language. All translated transcripts were given specific code numbers for maintaining anonymity and were put into a uniform format in Word 2003, by creating separate tables for each interview. The first table consisted of three columns, one each for transcription, translation, and code. Then, the transcripts, field notes, reflections, and other supporting documents were reviewed and reflected upon by the researcher

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with the supervisor and committee members. Transcripts were verified by listening to the audio-taped interview of each participant. Then, the researcher read and compared both the Urdu and English versions for similarities and differences, to explore more meanings and to develop a deeper understanding of the phenomena under study. The paragraphs from the transcripts that had similar meaning were then indexed with separate colours and codes, which were then written in the column of the first table alongside the transcripts. Another table was created that consisted of similar highlighted coloured codes from all the transcripts, subcategories, and categories. Sub-categories and categories were examined by using a tree diagram to identify meaningful relationships leading to the formation of a theme. Relevant quotes from all the transcripts were mentioned along with the transcript code number to support the description of the data. Finally, a framework was developed by analysing the data as a whole including the sub-categories, categories, and themes. Trustworthiness, as described by Lincoln and Guba (1985), includes credibility, confirmability, dependability, and transferability (Polit and Beck, 2008). The researcher found data saturation after interviewing six women but, to maintain credibility, four more participants were further interviewed to confirm that no new themes emerged. Member checking activity was done, in which the researcher requested two of the study participants to read their own transcripts and validate whether the transcripts captured whatever they intended to share. In addition to this, to ensure the rigour of the study, field notes were taken to note the non-verbal expressions of the participants. The researcher kept a record of her own reflections to allow for confirmability, to maintain an awareness of the potential for role conflict and to minimise the influence of the researcher's values on her interpretation of the participants' views (Polit and Beck, 2008). Triangulation was emphasised to reduce the effect of researcher bias (Shenton, 2004). Hence, to reduce researcher bias, data were collected from different sites (space triangulation) at different points in time (time triangulation). To ensure dependability the researcher stabilised the data by repeating the data collection and analysis methods in two similar settings with comparable participants. Hence, it was found that similar results were achieved (Shenton, 2004). The researcher found that the findings of the in-depth interviews provided the maximum description of the phenomena under study, allowing the readers to decide on the transferability of the findings to similar settings (Polit and Beck, 2008).

Findings A total of 10 women participated in this study. Their demographic data, analysed through frequencies and percentages, are presented in Table 1. These participants' ages ranged from 25 to 33 years; the average age was 28 years. All the participants were housewives. With regard to their family structure, four were living in extended families and six were from a nuclear family system. These women belonged to three different ethnic backgrounds; four were Mahajir, five were Sindhi, and one was Balochi. Pertaining to their level of education, two were uneducated, five had completed their primary education, and three had completed their secondary education. The monthly family income of the participants ranged from PRs. 10,000 to 15,000 (117–146 USD), with the mean income being PRs. 12,600 (123 USD). As the option of midwifery led care (MLC) is not offered to primigravidae, the participants selected for the study were between 2nd and 4th gravidae (number of pregnancies). A majority of the participants (n ¼5) were 3rd gravida, whereas, three participants were 2nd gravida, and two participants were 4th gravida. None of the

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Table 1 Demographic profile of the participants (n¼ 10). Characteristics Present age in years 25–27 28–30 31–33 Occupation Housewife Ethnicity Mahajir Sindhi Balochi Level of education Uneducated Primary Secondary Type of family Nuclear Extended Monthly income Rs. 10,000–12,000 Rs. 13,000–15,000 Number of pregnancies (gravida) 2 3 4 Number of alive children (para) 2 þ 0n 3 þ 0n 4 þ 0n

C

Frequency

%

3 5 2

30 50 20

10 4 5 1

100 40 50 10

A T TOPIC Perinatal Women’s Perceptions about Midwifery Led Model of Care (MLC)

Affordability of Midwifery Services

E THEME Women’s Satisfaction with MLC

G

Personalized Relationships

O R

2 5 3

20 50 30

6 4

60 40

E

4 6

40 60

S

3 5 2

30 50 20

3 5 2

30 50 20

participants had any history of either spontaneous or induced abortion. In-depth interviews were conducted in the Urdu language because all the participants felt comfortable in communicating in Urdu. The interview data were translated into the English language; however, to maintain the true essence of the phenomenon, in some of the narratives (quotes) Urdu was used with the English translation stated in parenthesis. For clarity, the word ‘sister’ used for midwife is in the narratives. Through analysis of the participants' interviews, a theme that emerged was ‘Women's Satisfaction with MLC.’ In this theme six categories were identified, which are: (1) admired capability and maturity, (2) affordability of midwifery services, (3) personalised relationship, (4) empowerment of women to make decisions, (5) presence, and (6) a voiced concern regarding lack of marketing of MLC (refer Fig. 1).

Admired Capability and Maturity of Midwives

I

Empowered Women to make Decisions

Presence

Voiced Concern related to Lack of Marketing of MLC

Fig. 1. Study findings.

Likewise, another participant discussed her postnatal experience and focused on the satisfaction of women with the midwives' expertise related to their knowledge. The participant expressed: …when I came with my baby for my first [postnatal] checkup, the sister explained the importance of family planning and its different methods to me. I was happy that she was so concerned about me and I was satisfied with her explanations about the various methods of family planning. (T7) Comparing her present and past experiences of the birthing process, one of the participants reported: Like my last delivery this time also the sisters' attitude was good and they were caring. They were always present with their patients. (T4) Likewise, another participant shared her feelings of satisfaction with MLC and appreciated that the midwives were experienced in providing intrapartum care. The participant said: [With a soft smile] the sister who conducted my delivery was experienced and was nice. She continuously provided me information about taking deep breaths during my pains … she rubbed my back to provide me comfort. That is why I felt satisfied. (T2)

Women's satisfaction with MLC On the basis of the analysis of their interview data, it was revealed that generally these women were satisfied with MLC during their antenatal, intrapartum, and postnatal periods. While describing their perceptions and experiences about MLC, the participants used words like expertise, experience, attitude and behaviour, presence, and personalised relationship. These experiences and feelings were presented succinctly and were supported by the participants' narratives. Sharing her experience of antenatal visits to a midwife and comparing this with a visit to an obstetrician, one of the participants said: She [midwife] is taking care of me like a doctor; you can't differentiate that a sister is checking you, it seems that a doctor is checking you. So the sisters here are expert at examining the patients. (T10)

Similarly, another participant highlighted the importance of the midwife's continuous support and her presence throughout the birthing process. She said: She [midwife] was always present beside me, which made me feel that there was some personalized engagement in our relationship. I was comfortable sharing my feelings with her and was satisfied with the care that she provided to me. (T9)

Category 1: admiring capability and maturity Women who were recipients of MLC acknowledged and appreciated the midwives' capability and maturity in dealing with women during the different phases of the childbirth process. The study participants shared that the midwives were knowledgeable, skilful, and capable in their fields. One of the participants, while expressing her views, shared:

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During pregnancy I was suffering from nausea and vomiting, I did not like to eat anything; therefore, I was not gaining weight. The sister told me that this was dangerous for my baby. She [midwife] provided me important information about food; like she told me to eat less quantity of meal but to eat at least 5 to 6 times a day. This helped me and I gained weight. I was very much satisfied with the information she provided me. (T1) Similarly, sharing her experience of receiving antenatal care from a midwife, one of the participants said: During this pregnancy, I felt tired, lethargic, and low, so I discussed this with the sister, and she taught me deep breathing and other relaxing exercises. She encouraged me to enhance my spirituality. These all [teachings] helped me gain strength and minimized my tiredness. (T3) Likewise, appreciating the midwife's knowledge in providing antenatal care to expecting mothers, one of the participants stated: Sister explained to me the reasons why ultrasound had to be done during my pregnancy. She told me that the first ultrasound is done to confirm the weeks of pregnancy; then the second is done when the fifth month of pregnancy is completed to detect abnormalities; and in the last month ultrasound is done to see the position of the baby [fetal lie] and to check whether the baby will be born normally or not. [With a smile on her face and feeling confident the participant said] you know; now I am well aware about the ultrasound. Now, if need be, I can even explain this to others. (T6) Moreover, acknowledging the midwives' competence in dealing with women during the antenatal period, one of the participants stated that: While doing my assessment [per abdominal examination], the sister's touch was very soft. She explained to me each step of the assessment. She used a machine [sonic aid] to listen to my baby's heart beat and told me that it was normal. This was a good experience and I felt happy. (T3) Comparing the midwives' expertise with their age, a number of participants reported that the age of the midwives did not matter as long as they were experts in their field. Expressing her views, one of the participants who was examined by a midwife during her antenatal period, expressed: The sister in the OPD [out-patient department], was very young, but she was expert in examining my tummy. She explained to me everything related to the examination and shared the findings with me. She also explained to me about the pregnancy marks on my abdomen [linea nigra and straie gravidarum]. I felt I was being treated well and was being involved in my care and I found that she had a lot of experience. (T7) Similarly, appreciating the expertise of the midwives in dealing with women during their intrapartum period, the participants acknowledged the importance of providing an explanation of the care by the midwives. Thus, expressing her views, one of the respondents stated: During my pains she [midwife] constantly emphasized to me to be relaxed and to take deep breaths, and made me lie down in a lateral position as a strategy for pain management and for the improvement of oxygen supply to my baby. (T2) During the intrapartum phase, viewing age as an indicator for expertise, one of the participants stated:

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… because the staff [midwife] was mature [in her age]. She was competent and she delivered my baby without giving me any stitches [episiotomy]. (T7) Apart from this, based on her feelings that caesarean sections are more often done by the obstetrician, and reflecting upon her observations, one of the respondents shared: In doctor's care, most of the time, a woman ends up with operation [caesarean section] but in a sister's care, the sister tries for normal delivery. She gives time and uses strategies like encouraging change in positions, deep breathing exercises, and guides about pushing at the right time. She provides constant support and is not in a hurry to deliver the baby. She lets the normal process proceed. (T3) Highlighting the importance of the midwife–patient ratio, particularly in the labour room, the participants desired a 1:1 ratio. However, there were participants who acknowledged the limitation of human resources in the labour room, but, supporting the staffing requirement, advocated for having a minimum of two midwives in a three bedded labour room. This is evident from some of the participants' narratives, as one of the respondents shared: A sister's role in labour is very important; she helps, guides, and supports the woman during pains. I would suggest having at least two midwives who should be mature [in age] and should be experienced, in the labour room, for better care provision. (T9) Acknowledging the importance of midwives' knowledge and expertise in dealing with women during their postnatal period, one of the participants expressed: I was not aware about the importance of initial breast milk [colostrum], and I may have not bothered about it; but the sister explained that it was good for my baby. She told me that this milk enhances the immunity of the baby, protects the baby from early infection. Thus, she encouraged me to feed my baby. (T2) Similarly, sharing her postnatal experience, another participant said: Sister explained to me thoroughly that breast feeding is also important for my own health. She told me that the more I feed my baby, the faster my uterus will contract and my bleeding [vaginal bleeding] will be controlled. (T10) In summary, the above mentioned excerpts indicate that in MLC, women found midwives to be capable, expert, and mature. Moreover, the women appreciated the midwives' knowledge and skills in providing care to women during the three phases of childbirth. Category 2: affordability of midwifery services Pertaining to affordability of midwifery services, the participants discussed the cost of facility-based childbirth and home birth and within the facility-based childbirth they compared the cost of a midwife's care with the cost of obstetric care. With regard to the affordability of maternity services, a few of the participants, based on the observations and experiences of their relatives, compared the cost of facility-based birth with the cost of home birth attended by traditional birth attendants, [TBAs], that is, ‘dais.’ The participants indicated that the maternity service charges of ‘dais’ were less in comparison to the facility-based births conducted by midwives. However, the participants raised

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their concern about the lack of competency of ‘dais’ to deal with emergencies, which may arise during the birthing process. As one of the respondents expressed: Although, home delivery is affordable but a dai [TBA], can only deal with normal cases and if emergency arises, she is not competent to deal with it. This is dangerous for the mother and the baby both. Therefore, in comparison to home delivery, the cost of facility-based delivery is high; but it is worth spending that money. You are satisfied that you are in safe hands; and in case of emergency, it is dealt with in time. (T6) Comparing the cost of care with other institutions, generally, the participants responded that the cost of midwives' care was high, but, they valued the maternity services provided in both the study settings. The participants felt comfortable in these two settings as infection control policies are followed there. As one of the participants expressed: If we see outside [in other institutions], maternity services are provided at a lower cost, but to prevent from infection precautions are not being taken. This can end up in problems for the mother and her baby. Therefore, we come here. Here the facilities are good for preventing infection, precautions are taken, staff is expert, and in case of an emergency, a doctor is always available. We [women and their families] are not afraid that our care will be mismanaged, so we are assured and satisfied. (T5) Moreover, comparing the cost of MLC with obstetric-led care, unanimously the women expressed that they had the power to purchase MLC services. In MLC, the cost for spontaneous vaginal childbirth is PRs. 8000–9000 (78–88 USD); whereas the cost for the obstetrician varies, in terms of whether the doctor is a Registered Medical Officer (RMO) or a consultant, ranging from PRs. 14,000 to 18,000 (137–176 USD) (Zar, personal communication, December 5, 2011). Discussing the affordability of MLC services, all the participants acknowledged that they were able to afford MLC. As one of the participants, focusing on normality of birth and comparing the cost of MLC with obstetric care, stated: When delivery is to be done normally, so it is better to register as a sister's case [MLC] rather than as an obstetric case, as the cost of a sister's care is less and affordable. (T2) In addition, another respondent, also focusing on the normality of childbirth, believed that it was in the hands Allah [God] to deliver the baby normally. The participant shared: I believe that it is Allah's decision to deliver the baby normally; hence, it is better to register under care of sister because we can afford those charges. (T9) A few of the participants compared the cost of MLC with obstetric care in terms of the continuous presence of the midwife and obstetrician during the intrapartum period. The participant stated: The cost of the doctor [obstetrician] is more and a sister's cost is less; but still, sister is always available with the patient in the labour room, and the doctor is not always there. (T6) Likewise, another participant, discussing the cost of MLC, highlighted the similarity in facilities, during the antenatal, intrapartum, and postnatal periods, provided by the midwife and the obstetrician. The participant said: You get similar facilities when you opt for a sister care, although the charges of [an] obstetric care are more. Thus, the sister care is affordable, so I think that it is better to go for it. (T4)

Relating to the affordability of the cost of maternity services, the respondents reported that the cost of MLC is affordable even by women who are from the lower socio-economic group. As one of the participants mentioned: Women, whose family income is less, can go for a sister's care and have a safe delivery, because a sister's care is affordable for women. (T7) Similarly, another participant discussed her perceptions about affordability of maternity services by women belonging to families where there is only one earning member, where affording maternity services can become an issue. In such families, women's husbands have the major responsibility for taking care of all the family members equally. The participant shared: In families where only one person is the earning member who has to look after the whole house, the children, and other family members, then how could women belonging to those families afford the cost of maternity services? As services in a sister's care and [an] obstetric care are the same, so it is better to register as a sister's case. (T3) To conclude, the participants found MLC to be an affordable maternity care service. They highlighted the similarity of service provisions in MLC and in obstetrician care, in spite of the differences in cost. The participants also discussed about the experience and expertise of a midwife related to intrapartum care, and compared it with that of the obstetrician's skills, in terms of the cost involved. Women also mentioned cost and linked it with the presence of the care provider, that is, a midwife or obstetrician. In addition, women indicated the importance of the cost of MLC with regard to low income generating families and women living in extended families. They also shared that unnecessary interventions during the intrapartum period lead to increased cost in services. Category 3: personalised relationship Personalised relationship refers to the development of a pleasing bond between the woman and the midwife during different phases of childbirth. The personalised relationship makes the woman feel that someone very near to her heart is with her. Pertinent to the personalised relationship, most of the women reported that midwives were caring and attentively listened to them during the antepartum, intrapartum, and postpartum periods. In addition, most of the women developed an open relationship with the midwives during childbirth, but particularly more so during the antenatal and the intrapartum periods. The following paragraphs will discuss the engaging relationships during the different phases of childbirth. Related to the development of the engaging relationship between the woman and the midwife during the antenatal period, most of the women discussed that midwives had a caring attitude and they had effective communication skills. One of the participants, while sharing her antenatal care experience, appreciated the communication skills and effective listening skills of the midwife by expressing: During pregnancy, when I came for my checkup, I found that the sister spoke very softly, and she actively listened to my concerns that I shared with her. She was soft handed while she examined me. I found an attachment with her and I am very satisfied with the attitude and behavior of the sister. (T3) With regard to the engaging relationships during the intrapartum period, one of the participants indicated that a midwife's communication skills are very important and it matters a lot

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during different phases of childbirth, but effective communication skills are very much appreciated during the intrapartum period. During labour women feel extreme pain so they want a midwife to be soft spoken, humble, caring, polite, and an attentive listener. As one of the participants indicated: It is very important that the sister has good communication skills, mainly in the pre-labour room and labour room, because at that time the patient's condition is also not good, and she is under stress. While I was in the labour room, the sister was gentle in her approach, her touch was caring, and she was listening to my concerns and was constantly reassuring me. (T5) Similarly, focusing on the women's feelings of engagement with midwives, one of the participants indicated that the development of a pleasant relationship between the women and the midwives during the intrapartum period is very important. This relationship helps in minimising stress and encourages women to share their concerns with the midwife. Moreover, due to the openness in the relationship of the women and the midwife during labour, the women consider the midwives as one of their close family members. As one of the participants indicated: It seemed that the sister was one of my own. She used to calmly talk to me, and she was there, and supported me during my pains. During pains you want someone who is very close to you to support you. As the sister was with me so I did not feel that she was an outsider. I felt that I had a personal relationship with her. (T3) Likewise, another participant had a similar view, as in the above mentioned excerpt, and she further emphasised that a midwife's continuous presence and good attitude during the intrapartum period allowed the woman to get closer to her midwife. She shared: From my entry in the labour room till my delivery the sister was constantly around me; she was available when I needed her. Through her approach I built a trusting relationship with her and felt an attachment with her (T9). Furthermore, with respect to personalised relationship, some of the participants shared that during the intrapartum period women suffer from fear of the unknown. Simultaneously, they are in pain and distress. In this state, the participants indicated that, as they felt more attached to and were open with midwives as compared to the obstetrician, they felt less fearful during the process of labour [and birth of the baby] due to their presence. One of the participants, sharing her perception, stated: When a woman is registered as a sister's case, then she does not feel frightened; whereas she really feels scared of the doctor [smiled]. The patient does not know much about the doctor and her behaviour, as compared to that of the sister's behavior, which is mostly good; and we know her because, most of the time, she is near to the woman. (T3) While expressing their perceptions and experiences about MLC, a few of the women highlighted the midwives' tolerance while caring for the women during the different phases of childbirth. One of the participants shared her observations regarding a midwife's tolerance during the intrapartum period and linked it with the development of a positive woman–midwife relationship. This relationship focused on friendliness and openness between a woman and a midwife. Pertaining to a midwife's tolerance during the intrapartum period, one of the participants commented:

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The sister worked with great patience while I was in labour pains; she listened to me and replied to my concerns, she did not shout at me. This behavior of the sister made me close to her and I shared my problems with her. (T7) Regarding the personalised relationship during the postnatal period, the participants were satisfied with the caring attitude and timely responsiveness of the midwife. The participants also discussed that during their postnatal period in the ward, they found that the midwives co-operated with them. As one of the participants shared: The sisters in the ward were very nice and cooperative; they attentively listened to my problem about breast feeding the baby, like I did not have much milk to feed my baby. So the sister explained to me that initially the milk flow is slow then as the baby sucks so more milk is produced. She sat beside me and assisted me in feeding my baby. I felt that she was concerned because she gave me individual attention, so I became satisfied with her. (T6) Apart from this, a few of the participants reported that although the attitude of the midwives was good they suggested that midwives should be soft spoken, particularly during the intrapartum period. One of the participants expressed: Sisters' attitude is good; however, I feel that there is still a need for the midwives to be softer in their communication especially when a woman is having labour pains. (T4) Overall, the above mentioned narratives, extracted from the indepth interviews, showed that there was a personalised and engaging relationship between the women and the midwives during different phases of childbirth that led to the women's satisfaction. The women shared that the midwives were caring, cooperative, and friendly. Moreover, the participants also expressed that the midwives' presence during labour, and their effective communication skills, helped in developing a personal relationship with them. In addition, the women felt less fear during labour because of the positive attitude of the midwives. Category 4: empowered women to make decisions This category discusses empowering women to make decisions, through the provision of appropriate information to women by the midwives during the different phases of childbirth, particularly during the intrapartum and postnatal periods. Most of the women shared that in MLC they were empowered to make decisions about their care, including positioning during childbirth and selection of pain management strategies. Moreover, the women expressed satisfaction that their religious values and beliefs were respected by the midwives during the postnatal period. A few of the women shared their experiences in terms of making decisions for themselves, mainly during the intrapartum period. The women discussed that they were given choices about different positions, such as sitting or lying in a lateral position during labour. Moreover, the women were allowed to make decisions that satisfied them. As one of the participants expressed: When I was having pains, at that time the sister guided me about many things that comforted me. She told me that I could sit and also lie in left lateral position; but she left the decision to me, and said that it is up to you [that] how you relax yourself during pains. (T6) Similarly, some of the women also discussed that during the intrapartum period when they were suffering from extreme pain, the midwives explained to them the different pain management

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strategies, such as administration of analgesia or back massage. One of the participants shared: When I had the labour pains, I felt that someone was stabbing a knife in my back. I asked the sister to help me relieve my discomfort. The sister told me about using pain killer injections and she also told me about massaging the waist; and she said that the decision was mine; I could go for any option. [With a soft smile] I asked the sister to massage my back to relax myself and minimize the pain, as she was there. (T10) Likewise, some of the participants also shared that during the intrapartum period, the women were empowered by the midwife to make safe decisions, and it helped them to cope with their labour pains. Moreover, the women's continuous involvement in their childbirth care helped them minimise their fear about the unknown. As one of the study participants stated: During my pains, the sister tried to help me relieve my discomfort; she involved me in my care. She shared, periodically, what was happening with me. She also communicated to me the findings of my internal examination [vaginal examination]. I was aware what was happening with me; I asked her to rub my back and she did it gently and I was very much relaxed. (T9) Another study participant, discussing her intrapartum experience, highlighted that the midwife gave her the choice of selection between various options, instead of imposing her decisions upon the woman, and she respected the woman's choices. The participant stated: The good thing about the sister's care was that she did not force me to do as she instructed me. She relied on my decision, but as she explained everything to me, I was very satisfied with her attitude. You know [staring and leaning forward], by doing this, the woman and sister relationship goes well, because she respected my choices. (T10) Yet, another participant expressed her feelings about being provided appropriate choices related to different positions during the intrapartum period, and about the pain relieving strategy, i.e., back massage. The participant mentioned: When I was in labour the sister gave me freedom in a few things, as she asked me whether I wanted to lie down or sit. She also said that back massage will soothe my pain; so I asked for it [back massage]. I felt good about it that she gave me a choice about what I wanted and was safe for me. (T7) Related to the women's empowerment during the postnatal period, one of the study participants discussed that the midwife respected her choice about feeding the baby. The participant did not want to breast feed her baby until verses from the Holy Quran [Azan] had been recited in the baby's ear. As the participant reported: That sister instructed me to breast feed my baby but I told her that I will feed my baby after she listens to the Azan. She respected my religious belief and did not force me to feed my baby and waited till my baby heard the Azan. After she had heard the Azan I breastfed her. I liked the way she respected my feelings. (T6) On the basis of the above mentioned excerpts, it is revealed that the women were empowered to make decisions after having been provided complete information related to their care. They were empowered to make choices for their care and be decision makers for themselves. The midwives respected the women's ability to make appropriate and effective decisions related to

positions during labour and pain management strategies. In addition, the midwives also respected the women's religious rituals and did not force the women to follow their commands unnecessarily. Category 5: presence This category discusses the presence of the midwives and the continuity of care provided by them particularly during the intrapartum period. Most of the women acknowledged the presence of the midwives throughout their stay in the labour room. The women found this to be a big support during their labour process. They also viewed it as important for the continuity of care. Furthermore, some of the participants indicated that continuity of care was also important during the postnatal period. One of the participants related the midwife's presence in the labour room as one of the supportive strategies for the management of her labour pain. She shared: When I was in the labour room, the sister was always there with me; she comforted me, and she rubbed my waist. I felt I was being cared and looked after well. She reassured me and gave me courage, and I was very much satisfied. (T4) Similarly, appreciating the presence of the midwife during the intrapartum period, another participant said: When I was in the labour room, the sister assessed me regularly; she frequently checked my labour pains, she explained to me and encouraged me to take deep breaths during the pains. She also instructed me to position myself comfortably and she continuously checked my baby's heartbeat. Then she kept me updated with the progress of my labour. I felt I was being involved in my care and the sister was all the time there with me. (T6) Likewise, another participant, reflecting on her birthing experiences, discussed that the midwife's continuous presence during the intrapartum period helped in building a rapport and a trusting relationship between the woman and the midwife. The participant expressed: The sister was always present there in the labour room. At times she had to go out for her work and to see another patient in the labour room, but, mostly, she was with me. Having her with me, I started trusting her. I was more attached to her because I discussed everything with her and she was also very supportive, as compared to the doctor. (T9) Some of the participants insisted on being cared for by the same midwife during the antenatal, intrapartum, and postnatal periods. The participants reported that the continuity of care by the same midwife is important to develop an understanding between the midwife and the woman, in order to enhance her satisfaction. One of the respondents said: Here different sisters take care of the patient during pregnancy, in the labour room, and in the ward. All the sisters are experienced and good in their work; but I felt that it would have been better if the same sister did my checkup when I was pregnant, then she delivered my baby, and after that she took care of me in the ward. I would have been more satisfied. (T3) Similarly, some of the participants expressed that continuity of care by the same midwife helps the midwife to be well aware of the woman's condition and enhances her satisfaction. One of the participants said: One who knows about you, and is knowledgeable about your history, if she does the checkup and conducts [the] delivery,

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then you feel more satisfied, as compared to being dealt [with] by a new person. (T2) Likewise, another participant shared her feelings and emphasised the continuity of care by the same midwife during all the three phases of childbirth, that is the antenatal, intrapartum, and postnatal periods. The participant stated: I feel that the presence of the same nurse during pregnancy, labour room, and in the ward will give more satisfaction and happiness…. (T9) In addition, some of the participants discussed their intrapartum experience in terms of the midwife–patient ratio. The participants noted that an inappropriate midwife–patient ratio, that is, 1:3 [one midwife and three patients] hindered a midwife's continuous presence in the labour room. Hence, a few of the participants commented on the importance of an appropriate midwife–patient ratio and suggested that one midwife should be present with one patient during the intrapartum period. As one of the participants shared:

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Apart from the intrapartum care, some of the study participants also pointed out the importance of continuity of care during the postnatal period. They mentioned that the continuity of care by the same midwife in the post partum phase can help enhance women's satisfaction. As one of the participants expressed: In the ward I did not see the sister who delivered me. The doctors were visiting me; they even checked my stitches. The labour nurse did not come to see me after my delivery, only the duty nurses were coming to me. I wished that the one who conducted my delivery would visit me at least once in the ward; I would have been more satisfied. (T2) In summary, the women preferred the midwives to be there during the different phases of childbirth. They also suggested that during the antenatal, intrapartum, and postnatal periods, continuity of care by the same midwife should be ensured. Moreover, the women also emphasised having an appropriate midwife– patient ratio during the intrapartum period as this will enhance women's satisfaction. Category 6: a voiced concern regarding lack of marketing of MLC

When I was in the labour room, there were already 2 other patients, but there was only one sister and she had to look after every patient. I had to call her again and again; she was not able to be with me all the time. In the labour room, every patient needs someone to be there for support and comfort, especially during pains. It is important that every patient should have a midwife taking care of her during labour. (T2) Moreover, the participants also expressed that due to the increased workload, the midwife's presence in the labour room was being affected. Hence, most of the participants suggested that, to provide maximum care to the women during the intrapartum period, more midwives should be assigned in the labour room. One of the participants commented: In the labour room, more staff is required to provide good and sufficient care to the women; less staff cannot give the proper and required care to the patients during the delivery of the baby. (T9) Focusing on the midwives' role during the intrapartum period and their workload, a few of the participants also suggested that one of the family members should be allowed to visit the women in the labour room. This will also minimise the burden of care on the midwives. The participant said: To reduce the burden of patient care on the staff [midwife] during labour, family members should be allowed to come and visit the patient in labour room;… (T7) In terms of the midwife's presence, a few of the participants compared the presence of a midwife with that of the obstetrician during the intrapartum period. The participants found that most of the time the midwives were present in the labour room with the women; whereas the obstetrician was not always present in the labour room. Thus, due to the continual presence of the midwives, a rapport was developed with the women. Expressing her views, one of the participants commented: The sister was always present in the labour room with me. I shared my feelings with her. Whenever I found myself in discomfort she was there to listen to my concerns. I found that a relationship was built between us. But, if I compare this with a doctor [obstetrician], the doctor was not always available there in the labour room. They came to visit and then went back. (T3)

This category discusses concerns raised by the participants about lack of marketing of MLC. Some of the participants expressed that proper marketing of MLC is not done by the institution. Participants showed their concern by focusing on women's right to access MLC. Furthermore, the participants shared that due to lack of marketing, there is a lack of awareness about MLC. Sharing their own experiences the participants said that their friends, family members, and neighbours were the source of information. As one of the participants said: People usually do not have awareness about the sister care, whereas it is important that they should be aware about this facility. So if anybody who cannot afford to go to a doctor, she can come here for the sister care. (T7) Similarly, another participant who came to know about MLC from her sister-in-law expressed: Through my sister-in-law I came to know about the sister's care. One of my relatives had a nice experience and she shared that the sister who delivered her did not give any stitches [episiotomy]. (T6) Among the participants for whom their neighbours were the source of information about the midwife's care, one of the participants indicated: I did not know about the sister's care; my neighbor told me about it. She told me that here the sisters are experts in delivery and they deal with the patients nicely. I also registered for a sister's care and experienced that sisters are very good and they are expert at delivering the baby. Their attitude is also good with the patient. (T10) One of the participants, who was registered for a second time under the midwife's care, expressed: My previous delivery was also conducted by the sister, she was very experienced. This time also my experience was very good. The sister was very much caring; she was there for me, she rubbed my back, supported me during my pains, and was reassuring and relaxing. (T6) In summary, the women who went for midwives' services were themselves the main marketing source for MLC. Though this is a good strategy, to increase the clientele, there is a need to enhance

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the marketing and promotion of MLC on a larger scale. Hence, it is suggested that marketing of MLC should be done so that people who cannot afford care by obstetricians can have more access to MLC, and have safer childbirths.

Discussion This study explored women's perceptions about MLC. The women's satisfaction with MLC emerged as the major theme, based on their experiences during the antenatal, intrapartum, and postnatal periods. MLC addresses the individual woman's needs; therefore, generally the participants were satisfied with the care provided to them by the midwives. This finding is consistent with the literature review reported by Pope et al. (2001), which indicates that women-centred care enhances satisfaction with childbirth. Moreover, participants in this study compared the two modalities, obstetric-led care and MLC and, based on their perceptions, they reported a greater sense of satisfaction with MLC. In terms of the different phases of childbirth, the participants of this study felt satisfied because of the high interest of the midwives in the women's health, continuity of care, cost effectiveness, and positive birth outcomes. Through midwives' continuous counselling, health education, and supportive behaviour, the women had a smooth transition from the antenatal to the postnatal period; regardless of the intrapartum period being intense and exhausting. These findings are in tune with the findings reported by Waldenstrom et al. (1997), in Stockholm birth centre trail with the sample of 1860 low risk women indicating that women feel satisfaction with childbirth when their expectations are met and they have a positive birth outcome. Spontaneous vaginal births were one of the important components that enhanced satisfaction with MLC. The findings revealed that the participants expressed satisfaction with the maternity services offered by the midwives due to their expertise and experience. In addition to that, they related their satisfaction to the way in which they were involved and their co-operation was obtained, and interventions such as episiotomy were minimised. The participants also perceived a decline in the rate of caesarean births and an enhancement in normal birth. This finding is consistent with the other studies and Cochrane review indicating that medical interventions are minimised and women’s satisfaction is enhanced in MLC (Pope et al., 2001; Hodnett, 2004; Reime et al., 2004; Stahl and Geburtshilfe, 2009). Reflecting upon their experiences, the participants also perceived a decline in the use of analgesia during labour and they reported that alternative interventions were used by midwives for labour pain management, such as deep breathing exercises and back massage, which led to a soothing and relaxing experience. Studies conducted on different populations have concluded that back massage reduces the intensity of labour pains by relaxing and soothing the muscles and improves women's sense of well-being during labour (Naushin, 2008), and analgesia use during labour is minimised (Hundley et al., 1994; Waldenstrom, 1998). The participants of the study also emphasised that midwives practicing at the study sites were specialised in providing maternity care to women during different phases of childbirth and were also trained to manage and refer complicated cases to the next level of care in which either an obstetrician is called or the woman is transferred. Some of the participants also reported that the ‘dais’ were not expert at managing and referring the complicated cases on time, it is important that arrangements should be made for early referral, including presumptive shifting for obstetrical emergencies, to prevent delay in initiating care (Murphy and Fullerton, 1998; Rasool, 2010).

Although the study participants were satisfied with MLC, they expressed a desire for an increased midwife–woman ratio in the labour room, that is, instead of it being 1:3 it should be 1:1. This finding supports the findings reported by McCourt et al. (1998) indicating that the midwife–woman ratio during childbirth is important to increase satisfaction with care. Focusing on midwives' approach towards women, there was a sense of satisfaction in terms of comfort. Highlighting the importance of comfort between the woman and the care provider, the participants shared that they were more comfortable with midwives as compared to obstetricians. The participants indicated this is an important component as it helped them in minimising their anxiety and fear related to the birthing process. These findings support the findings reported by Morgan et al. (1998), which indicated that a woman's satisfaction gets enhanced when there is friendliness, support, and good communication and rapport from the care provider. The present study also revealed that the interactions of women with their midwives motivated them to discuss their concerns with the midwives. This resulted in building a companionship with the midwives (Waldenstrom and Nilsson, 1993; Waldenstrom, 1998; O' Connor et al., 2009). However, a few of the participants alluded to the need for the midwives to be soft spoken, humble, polite, and attentive listeners, especially during the intrapartum period. Similarly, Hodnett (2002), Proctor (1998), Waldenstrom (1998), and Brown and Lumley (1998) have reported that the attitude and behaviour of the care provider is very important for providing comfort to the women, and it plays a crucial role during the birthing process. Building on the rationale for women's comfort with the care provider's approach, the midwives' patience was the driving force that enhanced the women's satisfaction with the emotional support provided during labour. These findings are consistent with the findings of other studies which revealed that successful communication, listening to women, and providing them emotional support are some of the key indicators for high quality maternity care (Hundley et al., 2001; Hodnett, 2002; Stahl and Geburtshilfe, 2009). The study findings are also consistent with evidence (Pope et al., 2001) that midwives should allow the women to choose certain options during labour and birth, such as options for labour pain management, and that midwives should involve women in their maternity care and empower them to make decisions on their own. Hence, the use of this approach leads to a positive relationship between the women and the midwife enhancing the women's selfefficacy and their control giving them a sense of satisfaction with the care provided by the midwives (Brown and Lumley, 1998; Morgan et al., 1998; Hodnett, 2002; Goodman et al., 2004). The study findings show that care during childbirth was provided by a group of midwives. The participants would have preferred to be cared for by the same midwife from their time of registration until the follow-up in the postnatal clinics for continuity of care. Studies conducted by Waldenstrom (1998) and Hundley et al. (1995) reported that continuity of care by the same midwife is highly appreciated to minimise confusion and to enhance satisfaction with maternity care. Moreover, care provided by a known midwife helps the woman retain her sense of control because the woman feels that the midwife is well-equipped to provide the relevant information (Green et al., 1990; Brown and Lumley, 1998; Waldenstrom, 1998). Comparing the cost of care provided by the obstetricians and midwives, the participants of the study reported that MLC was cost-effective and they were able to afford it. This finding is consistent with the findings of other studies, which indicate the cost-effectiveness of MLC in comparison to obstetric-led care (Schroeder et al., 2012; Ryan et al., in press).

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The participants also shared that as MLC was cost-effective so women from the low income families and extended families could also access it. This allows women with limited resources to receive affordable maternity care with safe outcomes (Hatem et al., 2008). Moreover, this allowed women to receive quality maternity care that was women-centred, focusing on safe childbirth and the birth of a healthy baby. The findings of this study indicated that women found midwives safe, competent, and desirable care providers, who used fewer medical interventions and provided economical maternity care during different phases of childbirth (Rana et al., 2003; Schroeder et al., 2012; Ryan et al., in press). The findings of the current study also revealed that in MLC women felt satisfaction because there was a balance between affordability of service and the quality of care provided by the midwives. However, the participants shared that the childbirths conducted by midwives in other maternity homes were cheaper, cost wise, as compared to MLC at the study settings; as the cost of those births ranged from PRs. 2000 to 3000 only (19–29 USD). Thus, reduction in cost of care at the study setting was requested by the participants. A few of the participants reported that the service charges of ‘dais,’ for home birth, were less than the amount charged in the facility but the quality of care provision by the ‘dais’ was questionable. This echoes the findings of the study conducted by Rasool (2010), which said that the ‘dais’ conduct childbirths at a lower cost. The participants of the current study also expressed that in home births minimal medical interventions are used, so the cost of care is less as compared to the facility-based childbirth. In Pakistan home birth conducted by ‘dais’ [TBAs] is a cultural norm, because it is believed that childbirth is a natural process that does not require any medical intervention; women prefer to go to the ‘dai’ who is easily available and is not expensive (Shahnaz, 2010). None of the study participants discussed the in-kind charges, but, in general, the in-kind charges (for example: animals, cereals, clothes, sweets) are added to the service cost provided by ‘dais,’ which ultimately increases the total cost of care, which is usually not considered while calculating the total net cost. The participants of the study viewed childbirth as a natural event so they expected normality during the birth of the baby. Studies have revealed that there is no major difference with respect to perinatal death and adverse maternal outcomes between home births conducted by midwives and planned hospital birth attended by a midwife or an obstetrician, or between facility- and home-based care (Olsen, 1997; Janssen et al., 2002; Janssen et al., 2009). Evidence from these studies highlights the need for a sustainable planned home birth policy which would parallel facility-based childbirths, because it is one of the basic rights of women to have choice in the location of birth. Moreover, the midwives should also be knowledgeable and experts in attending to home births (Fullerton et al., 2007). Most of the participants in this study reflected that the personal experiences of the women and the experiences of their friends and family members were the main source of information about the availability of MLC services. Women felt that this ‘word of mouth’ marketing strategy was very effective and that it motivated them to register for MLC. This finding is consistent with the findings reported in earlier studies, indicating that previous experiences and satisfaction with care support the opportunities to utilise those services again (Morgan et al., 1998). But for every woman, the above mentioned strategy will not be effective, so there is a need for identifying more effective marketing strategies for MLC. The women's statements support this. In terms of marketing, open houses for MLC are not planned, but open houses to advocate promotion of obstetric services and to increase clientele in obstetrician care are held, in which special cost reduction packages are offered for the clientele. Consequently, due to lack of awareness about MLC, the registration of women opting for it

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has decreased. If the secondary sites would like to be role models within the society as women-centred and women-friendly maternity care providers, then they might have to consider addressing the expectations of women, that is, each woman should have access to a midwife. Particularly at the secondary sites, the strategies employed for the marketing and promotion of MLC services were almost negligible; only panaflexes and banners for promoting MLC were placed at the entrance and in the nearby facility. Purposeful nonadvertisement or poor representation of MLC is a denial of the women's right to access MLC. One of the strengths of this study is the provision of baseline information about the significance and impact of MLC in promoting normal childbirth in Pakistan. During the literature review related to the topic under discussion, many international studies were found; the present study will add further to this body of scientific knowledge. To the best of the researcher's knowledge, this study is the first qualitative study on this topic in the Pakistani context. Thus, it provides the starting point for further qualitative and quantitative studies about the provision of MLC in Pakistan. A limitation of the study is that women enroled in this study gave birth during January to March, 2012, whereas data collection was done from April to June, 2012. Thus, the difference between the time of data collection and the women's experience about MLC was between two and three months. This may have resulted in recall bias by the study participants and they might not have been able to share their actual experiences. Additionally, there is no comparable data regarding MLC available from any other health care facility in Pakistan; this is considered as a limitation because no benchmark is available with which this study can be compared. Given that this is a small qualitative study, the findings cannot be generalised; however, the findings offer insights that may be transferable to other settings. This study holds strong implications for midwifery practice, education, research, and policy in Pakistan. The findings are useful for developing a women-centred midwifery curriculum. The findings of this study may also help to further the cause of advocating and providing women-friendly maternity care, by giving choice and control to women during childbirth, providing comfort to women by using fewer medical interventions, and promoting normality by attending spontaneous vaginal births. Moreover, as the findings show that women experience MLC as more affordable and accessible than obstetric-led care, those women who have participated in MLC can become advocates for midwifery practice both at home and in facilities. It must also be ensured that obstetricians are available to deal with complicated cases and the cases with more emergent care needs. This can support more effective and efficient utilisation of human resources for childbirth. The findings may enhance women's understanding about MLC and how it promotes normality of childbirth by focusing on individual women's needs and fulfilling their wishes, by being with them, listening to their concerns, and respecting their feelings during intrapartum care. It is hoped that the findings of this study will influence policy makers to take the lead in marketing MLC by focusing on the right of women to have access to maternity care. Additionally, the PNC could also engage in the promotion of the normality of childbirth, and encourage the practice of midwives. Other recommendations for marketing about MLC can include various strategies such as announcements in the media, community meetings, developing support groups for women, and holding open houses for MLC. Additionally, midwives must be allowed to have full scope of practice. Further studies should be conducted to explore the perceptions and experiences of women about MLC in other maternity care settings for comparison to the findings in this study. Studies can also be done to assess the availability, accessibility, and affordability of MLC in different maternity care centres in Pakistan. Moreover, studies can be conducted to assess the level

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of women's satisfaction during antenatal, intrapartum, and postnatal periods.

Conclusion The findings of the study revealed that the women who participated in MLC were satisfied with the services and the care provided to them by the midwives during the antenatal, intrapartum, and postnatal periods. The findings of the study further identified that these women were satisfied with the knowledge and competencies of the midwives; they highlighted the significance of the presence of the midwives and the continuity of care provided by them during childbirth. In addition, the women expressed satisfaction that they were involved in decisions about their care during childbirth. The participants found MLC to be affordable for them, although they wanted the cost of care to be reduced so that more women could get access to MLC. The respondents also raised concerns about the marketing strategy of MLC, as addressing this could increase MLC, making midwifery care more available to women in Pakistan.

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Perinatal women's perceptions about midwifery led model of care in secondary care hospitals in Karachi, Pakistan.

the purpose of this study was to explore the perceptions and experiences of perinatal women who have availed of midwifery led model of care (MLC) at s...
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