childbearing women's perceptions of nursing care that promotes dignity

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498 JOGNN Volume 33, Number 4

CLINICAL ISSUES

Childbearing Women’s Perceptions ofNursing Care That Promotes DignityRachel Matthews and Lynn Clark Callister

Objective: To gain an understanding of the per-ceptions of childbearing women about the mainte-nance of dignity while laboring and giving birth.

Design: Descriptive qualitative study.Setting: A university community in the western

United States.Patients/Participants: Twenty low-risk primi-

parous women who had recently given birth tohealthy term neonates.

Main Outcome Measures: Semistructuredaudio-taped interviews were conducted in the homesof participants using an interview guide.

Results: The following themes were identified:(a) nurses played a pivotal role in preserving dignityduring childbirth, (b) women appreciated feeling val-ued and respected, and (c) dignity was enhanced bynursing care that gave women their preferred level ofcontrol.

Conclusion: Nursing behaviors that demonstratevaluing and respect of childbearing women are essen-tial in preserving the quality of the birth experience.JOGNN, 33, 498-507; 2004. DOI: 10.1177/0884217504266896

Keywords: Control—Dignity—Labor—Nursingcare—Respect—Support

Accepted: May 2003

Entering a hospital is often an intimidating andstressful event for patients, as this is a world aboutwhich they may know very little. They may enterwith apprehension about the unknown or their ill-ness, or excitement about starting a new phase of lifewith the birth of a child. As they experience theunknown, patients may be told what to do and

when to do it, sometimes with little or no explana-tion. Tasks that health care personnel consider rou-tine are not only unfamiliar but also often very inva-sive, leaving the patient uncomfortable, helpless, orvery vulnerable. These feelings can lead to loss ofdignity.

Giving birth for the first time is a pivotal event inthe lives of most women. According to Corbett andCallister,

Few human experiences approach the intensity ofemotions, stress, anxiety, pain, and exertion thatcan occur during labor and birth. The events andinteractions that take place during labor may alsohave far-reaching and powerful psychosocial con-sequences. (2000, p. 71)

Although childbearing women’s perceptions ofbirth and its meaning are being documented(Kartchner & Callister, 2003), and qualitative stud-ies have demonstrated the importance of supportfrom nurses (Bowers, 2002), no studies have specif-ically focused on influences on women’s sense of dig-nity during childbirth. The purpose of this descrip-tive qualitative study was to gain an understandingof the perceptions of childbearing women aboutmaintenance of dignity while laboring and givingbirth.

Background

Dignity is a broad term and is often confusedwith other terms, such as modesty. One dimensionof dignity is a sense of being valued and respected(Lothian & Philip, 2001). Being treated with respectwas rated by childbearing women as among the five

July/August 2004 JOGNN 499

most important nurse caring behaviors (Manogin, Bech-tel, & Rami, 2000). Another dimension of dignity is hav-ing the desired level of control over decisions, fostering asense of self-efficacy (Bandura, 1977; Lothian & Philip,2001). Health care personnel, in an attempt to eliminatephysical risk to the patient, may sacrifice the patient’sautonomy (Shotten & Seedhouse, 1998).

Hodnett (2002) noted that a sense of personal controlis an important influence on satisfaction with childbirth.However, patients’ preferred degree of autonomy mayvary. Women approach childbirth with a range of person-al expectations about the care they will receive (Tumblin& Simkin, 2001). In an analysis of birth narratives thatfocused on women’s personal meanings of control, Van-deVusse (1999) concluded that the birth experience isvery complex and that viewing the needs of women holis-tically and contextually is essential. Lowe (2000, 2002)detailed numerous issues related to self-efficacy and per-sonal control in laboring women. Her work emphasizesthe complexity of influences on the quality of the birthexperience.

To grasp how nursing care is perceived by its recipientsand to continue to improve clinical practice, it is essentialto listen to the voices of childbearing women (Lothian,2003; Maternity Center Association, 2002a, 2002b;Weaver, 1998). The purpose of this qualitative researchstudy was to listen to women’s birth stories to shed lighton nursing practices that demonstrate respect and pre-serve dignity.

Method

SampleFollowing institutional review board approval,

announcements were posted in married student housingcomplexes at a western private university inviting child-bearing women to participate in the study. The targetpopulation was first-time mothers who had given birth inthe past 3 months. All prospective participants were con-sidered who were at least 18 years old and spoke English.

Twenty primiparas were interviewed. The women hadgiven birth to healthy term infants at a tertiary care cen-ter, a Level II facility, or a community hospital. Seven par-ticipants had certified nurse midwives as care providers,and 13 had physician caregivers. Seventeen of the womenhad epidural analgesia/anesthesia, and three had unmed-icated births. The mean length of labor was 11.5 hours.Four women had cesarean births, and 16 had vaginalbirths.

Seventy-six percent of the women had attended child-birth education classes. Mean maternal age was 23 years,and 71% had completed college, 14% had some collegeeducation, and 15% were college students. All of thestudy participants were healthy, low risk, White, mid-

dle class, and married. All of their husbands attended thebirths.

Data CollectionFollowing completion of consent and demographic

forms, an appointment was made for a 60-minute audio-taped interview to be held in the home of the study par-ticipant or at a place that was mutually convenient to theparticipant and investigators. In the research encounter,the respondent is looked upon as a “vessel of answers toquestions about . . . her experience” (Gubrium, 1994,p. 66). The semistructured interviews were collaborativedialogues, similar to those described by Kaufman (1991)as “structured conversations” (p. 21).

An interview guide to elicit issues related to dignitywas constructed based on Nichols’s (1996) work, the lit-erature, and clinical experience with childbearing women,with the goal of keeping the interviews both comprehen-sive and focused (Hutchinson & Wilson, 1992). First, thewoman was asked to describe her birth experience. Laterquestions included, “Did you ever feel a sense of loss ofcontrol during your labor and birth experience?” and“What is important for nurses to do to help women feelrespected?”

In response to broadly framed questions, participantswere given the opportunity to articulate their personalperspectives. Interviews moved from a general to a specif-ic focus as probing was used to elicit understanding, clar-ify expressions, and achieve saturation of thematic cate-gories. Follow-up interviews were conducted with fivestudy participants to enable them to clarify and amplifytheir perceptions and to verify the results of analysis.

Data AnalysisData collection and analysis occurred concurrently in a

process called “circles within circles” (Ely, Anzul, Fried-man, Garner, & Steimetz, 1991). In this process, linguis-tic rather than numerical data were analyzed to discoverthemes articulated by the participants (Reimen, 1986).The process was conducted as follows:

1. Each interview was analyzed before the next inter-view began.

2. Immediately following the interview, memos weremade on observations or insights gained in the inter-view process.

Interview questions included “What is important for nurses to

do to help women feel respected?”


3. Verbatim transcripts were made of the audiotapes,and the researcher listened to the tapes, studied thetranscripts, and made memos about major thematiccategories.

4. Transcripts were reviewed by the second author,who had expertise in qualitative inquiry, as suggest-ed by Lincoln and Guba (1985).

5. Transcripts were read and compared across par-ticipants.

6. Categories were densified and saturated throughcomparison and contrast of the data with clinicalexperiences of both researchers, past findings ofthe second author, and continuing review of theliterature.

7. Categories were modified as these sources werecompared.

8. When continuing data collection and analysis failedto uncover any new ideas, it was determined thatsaturation had occurred, and data collection wasconcluded. Saturation was demonstrated when itseemed that the participants were speaking from ascript, because they expressed thoughts similar tothose of other participants.

Trustworthiness was a priority throughout data collec-tion and analysis (Lincoln & Guba, 1985). Credibilitywas optimized by collecting data during an extended peri-od of time. Discussion with participants as the findingsevolved provided confirming insights (Miles & Huber-man, 1984). Researchers also discussed the final findingswith five study participants to verify that the themesreflected their experiences. The degree of transferabilityto other settings and groups was demonstrated bydescribing the depth and breadth of the interview dataand the characteristics of the sample and setting. Con-firmability was established by creating a track record ofmemos regarding insights gained in data collection andanalysis and was strengthened by collaboration betweenauthors (Richards, 1998).

Results

Women reported that giving birth was an extremelysignificant life event. Holding on to the special nature ofthe experience for each individual woman was essential.Laura said, “It’s important for nurses to know that themother is having what’s probably the most important dayof her life.” Acknowledging the special nature of the birthexperience and the centrality of the woman’s role in it waspart of nursing care that promoted women’s dignity.Themes of the women’s stories related to dignity included(a) nurses played a pivotal role in preserving dignity dur-ing childbirth, (b) women appreciated feeling valued and

respected, and (c) dignity was enhanced by care that gavewomen their preferred level of control.

Nurses Played a Pivotal Role in Preserving Dignity During Childbirth

Participants spoke again and again of the importanceof the nurse’s role in supporting them. The nurse’s pres-ence, encouragement, continuity of care, and knowledgemaintained women’s dignity. Many mothers expressedsurprise at the extent of the nurses’ role. For example, oneparticipant said,

The birthing experience doesn’t really matter with yourdoctor. He’s there the last 5 or 10 minutes. It’s thenurse that’s with you through the whole 12 hours. Sheplays even a bigger role than the doctor does becauseshe’s the one that’s in there all the time with you.

Other mothers expressed surprise that the physicianwas not more involved. Mary said she would have appre-ciated “a little bit more of the doctor’s interaction. I justthought he’d be a little bit more involved. He would justpoke his head in and sometimes not even talk to me andjust talk to the nurse.” Another mother was also disillu-sioned about the role her physician played in her birth:

I had a rose-colored vision that [the doctor] would bethere the whole time holding my hand and coachingme. I was completely stunned that he came in when thehead was crowning, completely stunned. Doctorsreally do just come in and catch the baby and that isabout it.

Several mothers mentioned that sincere concern andpositive attitude of the nurse helped establish an encour-aging birthing environment. Lindsey said of the triagenurse,

She seemed so excited to see us. She said, “This is soexciting! How long have you been having contrac-tions?” For me it was like, “Oh, I’m so excited. I’mgoing to have this baby.” She made me feel that I wasdoing a great and noble thing, having a baby.

Allison was able to achieve the unmedicated birth shewanted with the assistance of her nurse, “I just reallyloved the nurse. She was really upbeat and gave me a lotof compliments, like, ‘Oh, you’re doing a great job’ and‘you’re so strong.’ She was really supportive.” Diananeeded reassurance, encouragement, and validation fromher caregivers:

I was constantly asking, “Is everything okay? Am Idoing everything I need to do?” And they were great.They were like, “Yes, you’re doing great. You’re doingawesome.” You know, I think they were just as excitedas I was when I gave birth.


One mother spoke of the difference between her expec-tations and the reality of her birth experience: “This isn’twhat I thought it was going to be like.” She noted that thenurses helped her fearfulness subside, “Their confidenceeased my nervousness and scared feelings.”

Having a continuous caregiver present helped supportdignity. Kara, who had a 12-hour labor, said, “I had thesame nurse stay with me the whole time I was in labor. Itwas really nice to have help from somebody I knew thewhole time, and not have them keep switching on me.”

The nurse’s knowledge was a resource for the mothersand enhanced the nurse’s supporting role. For example,study participants were grateful that nurses were familiarwith complementary therapies such as acupressure,breathing techniques, hydrotherapy, ambulation, guidedimagery, and other relaxation techniques to help withpain management (Caton et al., 2002).

Women Appreciated Feeling Valued and RespectedParticipants expressed appreciation that their emo-

tions, decisions, physical comfort, and privacy were takenseriously. The perception that they were valued andrespected helped maintain a sense of dignity.

Their emotional reactions were not judged by the nurs-es. After a 12-hour labor, 23-year-old Brooke was told bythe nurse that there was a possibility that she would needa cesarean birth. Brooke said,

I was glad she told me that because I cried for proba-bly 20 or 30 minutes. It was good because I was ableto prepare myself mentally and emotionally for that tobe a possibility. Everyone was so helpful and support-ive, knowing that this was really hard for me emotion-ally.

Rebecca spoke of the empathy of the nurses: “Theyrespected the fact that I was in pain, that I had tears in myeyes and was about to cry.”

Nurses promoted dignity by honoring requests for painmedication and working to achieve physical comfort formothers during labor. Speaking of her caregiver, Cather-ine, a 25-year-old mother who was also a registered nurse,said, “She showed me respect. She let me do what I want-ed. And she gave me options. When I wanted the epidur-al she didn’t judge me or anything. She said, ‘That’s a

good choice for you.’” Another said that the nurses “tookevery measure they could to make me feel as comfortableas I possibly could be.” A third said, “I was supportedduring my labor. They [the nurses] let me try whatever Iwanted to get comfortable. They really had a personaltouch. It was so important to me.”

Feeling encouraged by nurses promoted dignity. Emilyspoke of the support she enjoyed from her nurse midwifecaregiver: “I actually liked having her there the wholetime because I felt like if I needed anything she was rightthere. She just kept saying, ‘You’re doing good, you’redoing fine.’” Lindsey also described the support she wasgiven:

The very last nurse I had when I was pushing, she wasvery supportive, encouraging me, telling me I wasdoing a really good job. Those things really helped. Toknow that this person who sees births all the timethinks you’re doing a good job, it really encouragesyou. I did a lot better pushing and breathing when shewas in the room.

For some women, exposure while laboring and givingbirth was an important threat to dignity, as LeeAnnexpressed: “You are so used to being a private person,and your body is your body. And then all of a suddenyour body is being checked out by 20 other people.” Sev-eral mothers mentioned that the nurses pulled the curtainin front of the door, so that if the door was opened, noone could see inside.

The number of caregivers in the room was bothersometo some study participants. The respiratory team from theNICU attended the birth of one mother, who suggested,“It would have been nice to have all those people waitoutside until the baby was born.” However, some moth-ers felt that their exposure was handled respectfully. Onemother said,

From my perspective it was just a beautiful and specialexperience. I didn’t feel that anybody treated it disre-spectfully, like it was something degrading. Even whenmy entire body was exposed to people, I never felt thatI was being violated or disrespected at all.

Laura described the balance between dignity and mod-esty for her: “Lack of dignity doesn’t even come down tolack of modesty. It’s just an issue of remembering that themother having the baby usually wants it to be a privateexperience, because it’s so significant and special.”

Dignity Was Enhanced by Care That GaveWomen Their Preferred Level of Control

The sense of being in control included feeling in con-trol of personal behavior, which often was related to painmanagement. Another type of control was having aninfluence on decisions and interventions. Individual dif-

Participants expressed appreciation that their emotions, decisions, physical comfort,

and privacy were taken seriously.

ferences and communication and information from careproviders affected women’s experiences of control.

Women’s desired level of control about decisions var-ied. Some felt very vulnerable and became passive, defer-ring to their caregivers to make decisions. For example,one study participant said, “I prefer to take advice from adoctor. He knows more than I do. I don’t want to makedecisions that I don’t know much about.” Another moth-er, describing being induced following spontaneous rup-ture of membranes, said, “I didn’t care. I’d do whatever ittakes. It wasn’t my decision to make.” Tara, a 20-year-oldwhose birth was attended by her husband and her moth-er, said, “I was confident in everyone’s ability to do theirjob. I was accepting of all the procedures that had to bedone. I just hoped that everything would be fine.”

Other women had strong desires to be involved in thedecision making. Alicia said, “I’m the one who’s in chargeof the childbirth experience, not the doctors, or the nurs-es, or the hospital. This is between me, the baby, and myhusband. Everybody else is there to support, not to takecontrol.” Anna felt a strong sense of self-efficacy follow-ing giving birth:

I would love it if all women were given the opportuni-ty to open their minds to what their bodies can reallydo, that the woman is in control of her own birth,instead of turning it into someone else’s experience. Meand my husband, it’s our experience. The midwife ordoctor and nurses are only there to help.

One woman suggested, “I wanted to be in control andmake decisions about my birth. She [the nurse midwife]let us decide what we wanted to do. Just basically thehelper instead of the boss.”

Brooke spoke of her sense of losing control when shelearned she would have a cesarean birth:

When they told me that I needed a c-section, I felt adefinite loss of control, because I felt like I didn’t havethe ability anymore to give birth to my baby. That now,somebody else had to do it. I still gave birth to him, butI felt like they were just going to take him from menow, rather than me working to get him here. So, thatwas kind of hard.

She also shared how the cesarean birth decision was han-dled to enable her to maintain control:

He [the doctor] said, “I’m recommending it to you asthe best decision.” So, he still left it up to me ultimate-ly. I realized for the safety of the baby, that was the bestchoice. Most of the decisions were left up to me. Hewas very encouraging and very supportive. I alwaysfelt that he cared about me as an individual and notjust a patient, like the millions of other patients that hesees every day.

Sherie spoke of the balance between feeling in controland being dependent on professional caregivers:

I felt like they were trying to involve me in makingdecisions and I had control in that way. But I know Icouldn’t do this by myself. I was at the hospitalbecause I needed professionals. I felt control but I feltvery dependent. You feel an absolute dependency onthe people who are helping you.

Kristen, who gave birth unmedicated, noted that

there is a difference between being delivered and givingbirth. I was giving birth and they [the nurse midwifeand nurse] were assisting me, rather than me just lay-ing there and being delivered. It was a team effort.There is a difference, and I was pleased. That’s the wayI wanted it.

Circumstances that affected the way some mothers per-ceived self-control included pain, fatigue, and the amountof information to which the mother had access. Twenty-year-old Tara spoke of her feelings of inadequacy and lackof control:

When I was at home and we were about to leave forthe hospital, I hugged my mom and said, “I can’t dothis.” When I was waiting for the anesthesiologist,sometimes my contractions were so bad I would justscream really loud. I just screamed. I was emotionallydrained. I think I definitely lost control emotionally,just screaming and crying. But I got more under con-trol as it went along and as I started focusing more onbreathing and concentrating on my husband while Iwas having a contraction, looking him in the eyes. Andit helped me regain my control and helped me feel bet-ter too.

Lindsey, whose goal for childbirth was to feel a sense ofcontrol, said,

I would have liked to have been more tough. I didn’tknow what to expect because I’d never had a babybefore. In my mind I kept thinking, “I’m going to be astough as I can, I’m going to go as long as I can, I’mgoing to breathe, I’m going to do all the things theyteach you about in prenatal classes.”

She was disappointed in herself when she asked for anepidural and was dissatisfied with how she felt afterward:

I felt frustrated being flat on my back. The contrac-tions were a lot harder and stronger when I was layingdown than when I was sitting up. I didn’t have the free-dom to sit up. I wish I’d asked more questions. I’d askthem to explain to me, “Why are you doing this? Whatis going on here?”


Allison explained how the nurse helped her and herhusband maintain a sense of control as they laboredtogether without medication: “The nurse helped me con-centrate on my breathing and helped Matt keep it togeth-er and focus on helping me breathe. That helped me feelmore dignity.” The balance of autonomy and direction inmaintaining personal control was also addressed byAngela, who said,

I got to the point where I remember thinking, “I’mdone. I can’t push any more.” The doctor and nurseshad to take over and say, “This is what you have to doand you’re going to do this and we will show youhow.” They were very positive, saying “You’re doinggreat, I can see the head, everything’s going well. Just afew more pushes and it will all be over.” They weregreat motivators when I really needed to keep going.Positive reinforcement was the most crucial when I waspushing. Especially toward the end.

Many women found that communicating effectivelywith providers was a key component of maintaining asense of control and promoting dignity. The quality ofcommunication between members of the health care teamwas also discussed by some of the mothers. Angela spokeof one way her nurse communicated during their initialinteraction:

[She] sat down on the bed and started to talk to usabout what was going to happen. I really liked itbecause it made me feel more comfortable. The factthat she sat down and was like, “Okay, let’s chat.” Soit wasn’t as imposing as someone standing over me andtelling me what was going to happen. I thought it wasa lot more friendly, a lot more relaxed.

Another participant talked about the importance of com-municating information to patients:

The more detail you give, the more information yougive your patient, within reason, is good for the patientbecause they really feel like they have control. Theyreally feel like that’s something that they have theopportunity to change.

Communicating regarding decisions was seen as essen-tial. Another study participant talked about having anepisiotomy without any discussion:

I don’t really think that I had a problem understandinganything. Nothing was really explained. The doctornever said anything to me about an episiotomy. He justcut and stitched me up and that was it. It was anunspoken decision.

Effective communication between members of thehealth care team was also essential to a sense of dignity,as expressed by Julie, who said, “They were working

together, which was nice. So I didn’t feel like I told oneperson and then the other had no clue. They seemed tocommunicate really well.”

Discussion

Women see childbirth as a pivotal life event. In the firstnational study of women’s memory of childbirth, Walden-strom (2003) concluded that although there is great vari-ation in women’s memories of childbirth, the experienceis a memorable one. Participants in this study articulatedthe need for nurses to demonstrate reverence for the birthexperience by sharing the joy, communicating clearly,deferring to the requests made by women, providingattentiveness and continuity of care, and appreciatingchildbearing women’s strength and courage in negotiatinga challenging experience.

In another qualitative work, Fowles (1998) inter-viewed mothers 2 months after giving birth, asking thissingle question, “Is there anything about your labor anddelivery that is still bothering you?” Mothers’ positiveresponses were related to the support they received andthe context of their birth experience. Negative responsesincluded lack of support, control, and knowledge. Whenexpectations were unmet, there was dissatisfaction,regardless of the level of childbirth pain experienced (Cal-lister et al., 2003; Young, 1998).

In a descriptive qualitative study of women who chosedifferent caregivers for a second birth, one multiparouswoman articulated a strong desire to have a differentbirth experience and stated,

I had my first one in a way I view as traditional, wherethe doctor was in control and he encouraged me tohave an epidural. It was such a frightening experience.Afterwards I thought, “This isn’t childbirth. There’sgot to be more to it than just laying there with a numbbody.” (Callister, 1995, p. 175)

Satisfaction with childbirth is strongly influenced byperceptions of caregiver support (Corbett & Callister,2000). In their study of nursing support during labor, thenursing behavior ranked highest by study participantswas “made me feel cared about as an individual.” Womenvalue this kind of support, regardless of how childbirthpain is managed. Study participants described supportiveactions by nurses who demonstrated respect and themaintenance of dignity, such as showing value for partic-ipants’ opinions, emotions, and decisions, and trustingthe patients’ perceptions of pain.

In the highly technological birth environment of today,women have a sense that giving birth is “high risk,” andthey are dependent on professional caregivers. This maycreate a sense of helplessness and lack of control (Cheung,2002). To optimize women’s sense of control during


childbirth, it is essential to remember that “professionalknowledge and power need to be supportive, not directiveof birthing processes” (VandeVusse, 1999, p. 49). Havinga sense of control is also positively correlated to satisfac-tion with childbirth (Green & Baston, 2003). Women’sperceptions are influenced by the philosophy of their care-givers. “Finding a fit” between the caregiver and thewoman is essential (Callister, 1995).

A limitation of this study was that participants wereWhite, middle class, had the fathers of their babies attend-ing their labor and birth, were well educated, and mostchose epidural anesthesia for pain management. Theymay have been more likely than less well-educatedwomen to seek education about childbirth and use infor-mation to maintain control and dignity. Most partici-pants’ choice of epidurals for pain management may haveinfluenced the findings by changing their experience ofcontrol and of the role of pain management and its sideeffects on women’s dignity. The finding that some womenfelt a loss of control when they had a totally numb bodyfrom the epidural and they could not move merits furtherinvestigation. Feelings of dissatisfaction or the sense ofnot having expectations met may have been overshad-owed by the positive outcome of a healthy neonate. Forsome women, the quality of the birth experience was lessimportant than issues of maternal and neonatal mortalityand morbidity. Future research might include develop-ment of a theoretical framework for labor support (Sauls,2002) and of an instrument that effectively measures per-ceived dignity in childbirth.

Implications for Clinical Practice

Approximately 6 million women become pregnant inthe United States each year. The results of this studydemonstrate the ongoing need for woman-centered peri-natal care. The World Health Organization Principles forPerinatal Care (Chalmers, Magiaterra, & Porter, 2001, p.203) include the following, which are echoed by the find-ings of this study: (a) care for normal pregnancy and birthshould be demedicalized, (b) care should be holistic, (c)care should involve women in decision making, and (d)care should respect the privacy, dignity, and confidential-ity of women. The Coalition for Improving MaternityServices (1996, p. 1) noted that, “A woman’s confidenceand ability to give birth and to care for her baby areenhanced or diminished by every person who gives hercare, and by the environment in which she gives birth.”Mackey and Stepans (1994) reported that women appre-ciated care in which “the nurses are supportive of whatyou want, who you are, and how you want to do things”(p. 416).

To promote dignity, nurses can demonstrate respect inthe way they address a woman. For example, calling her

“honey,” addressing her by her first name without askingwhat she would like to be called, or using a superior orcondescending tone and language may create the impres-sion of a disempowering environment, rather than reas-suring and friendly situation.

Nurses can demonstrate respect through listening andexpressing interest and by helping the mother to expressherself. When a nurse conveys interest and concern, anenvironment of trust may be established, and a mothermay be more likely to voice concerns, ask questions, and,therefore, feel more control over her situation. Similarly,in response to the mother who noted that this is probablythe most important day of a mother’s life, nurses candemonstrate respect by considering patients’ feelings firstand their own convenience later. Putting her feelings firstcan empower a woman and add to her sense of trust(Bright, Andrus, & Lunt, 2002).

Although the women in this study were mainly welleducated, some were quite young and less knowledgeableabout the birth process. Nurses must take care to demon-strate respect for those less educated, whether due to alack of childbirth education or lack of formal educationand low literacy. It is important to modify teaching stylesand methods to fit the level of education and ensure thateach mother achieves the amount of knowledge that shedesires and that is necessary. In addition, nurses shoulddemonstrate respect for women of all cultural heritagesand aim for culturally competent care through the acqui-sition of attitudes, knowledge, and skills to support cul-turally congruent birth practices (Callister, 2001). Thisincludes respecting and facilitating birthing practices thatmay be unfamiliar to the nurse.

According to Enkin and associates (2000, p. 328) andsupported by Mackey (1998), “Satisfaction with child-birth is not dependent on the absence of pain, but effec-tive pain management is essential to enhance the dignityof childbearing women.” Lowe (2002, p. 20) concludedthat “Choice among a variety of methods and individual-ization of pain-related care are desirable.” Excellent rec-ommendations have been made by the Maternity CenterAssociation (2002a, 2002b; Lothian, 2003) to assistwomen to manage their pain effectively in ways thatdemonstrate respect. Lowe noted, “There is a strikingqualitative difference between pain in the context of help-lessness, suffering, and loss, and pain in the context ofcoping resources, comfort, and a sense of accomplish-ment” (2002, p. S22).

Each woman should be supported in managing herpain with the goal that her personal expectations for herbirth experience are met. In a systematic review of painand women’s satisfaction with childbirth, Hodnett (2002)reminded nurses that,

Caregivers frequently assume that optimum pain reliefduring labor and birth is very important to most labor-


ing women, and that those who say they wish to avoidpharmacologic pain relief measures are either martyrsor misinformed. However, the results concerning theimpact of pain and pain relief on childbirth satisfactionwere consistent across a wide variety of circum-stances—when epidural analgesia was common orrare, across a wide variety of study designs and meth-ods, in a variety of countries, over almost 30 years.Pain and pain relief do not generally play major rolesin satisfaction with the childbirth experience: unlessexpectations regarding either are unmet. (p. 171)

An excellent consumer Web site reporting the best evi-dence on childbirth pain management is http://maternity-wise.org/nw/topics/pain (retrieved February 14, 2004).The long-term initiative of the Maternity Center Associa-tion on labor pain is an element of the Maternity CenterAssociation’s Maternity Wise program, which supportsevidence-based care of childbearing women and promoteswomen’s informed choices.

Simkin (2002) provided practical suggestions for nurs-es in the provision of supportive care for laboring women.Miltner (2002) suggested that nurses provide more sup-portive care than has been documented in previous stud-ies, calling for a model of “supportive surveillance” (p.760). Technology should be judiciously applied, with thefocus on the provision of an optimal birth experience(Enkin et al., 2000; Miesnik & Stringer, 2002; Wood,2003). After all, giving birth should be celebrated as abirthday party!

These findings can be applied to clinical practice bydemonstrating respect in interpersonal relationshipsbetween the nurse, the woman, and her family, valuingrespect of childbearing women and dignity and sharedpower in labor support implicitly and explicitly in unitculture; and writing respectful care behaviors into clinicaland administrative procedures and policy at the organiza-tional level, as well as into care standards of third-partypayers and nursing specialty organizations such as theAssociation of Women’s Health, Obstetric and NeonatalNurses (AWHONN, 2000) and regulatory bodies.

Conclusions

It is essential that nurses value and respect patients andpromote their dignity and self-worth. This can be accom-plished through participatory decision-making and foster-ing a sense of control through shared power. By doing so,nurses can make an important difference in the quality ofthe patient experience (Callister, 1993). According toRosen (2004, p. 30), “Overall, satisfaction with the birthexperience is highly associated with continuous, individu-alized, and emotional support.”

In a classic work, Highley and Mercer (1978) de-scribed what participants tried to convey to theresearchers:

Being able to assist a woman in one of the greatesttasks of her life—giving birth to and mothering ababy—is a privilege and challenge that touches everynurse who assists in her care. The challenge extendsnot only to the concrete physical help that the motherneeds, but to the subtle consideration and attentionwhich help her maintain her self-control and thus herself respect. (p. 41)

More recently, DeLellis (2000) expressed the importanceof valuing and promoting dignity in childbearing women:

The perinatal experience—an act of procreation, rite ofpassage, sacrifice of love, obligation of conscience,choice of fulfillment, or whatever it represents in theminds and hearts of birth-giving women and theircommunities—is a life-transforming object of respect.(p. viii)

May such respect be manifest in our care of childbearingwomen and families.

Acknowledgments

Funding is from Brigham Young University Office ofResearch and Creative Activities, and the Women’sResearch Institute.

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Rachel Matthews, RN, BS, is a staff nurse at the University ofUtah Medical Center.

Lynn Clark Callister, RN, PhD, FAAN, is a professor at the Col-lege of Nursing at Brigham Young University, Provo, UT.

Address for correspondence: Lynn Clark Callister, RN, PhD,FAAN, College of Nursing, Brigham Young University, Provo,UT 84602-5544; E-mail: [email protected].

Vicki Akin, CNS, MSNErin Anderson, RN, MSNJoan Rosen Bloch, PhD, CRNPCaroline Brown, DEd, CNS, WHNP, IBCLCLynn Clark Callister, RN, PhD, FAANAnita Catlin, DNSc, FNPSandra K. Cesario, RNC, PhDAndrea Christian, MS, RN, CNSPatricia Creehan, RN, MSN, CSDiane Holditch-Davis, RN, PhDBarbara Leary Dion, RNC, ICCE, MA, MSNPamela Dee Hill, RN, CBE, PhD, FAANDebra Hobbins, MSN, APRN, NPDebra Jackson, RNC, MPH, DScLori Jackson, RNC, NNPSheryd J. Jackson, RNC, MS, WHNPTeresa Johnson, PhD, RNSusan Kardong-Edgren, RNC, MS, FACCEVirginia L. Kinnick, RN, CNM, EdDGail Schoen Lemaire, PhD, APRN, BCLynne P. Lewallen, RN, PhDLouise K. Martell, RN, MN, PhDPatricia R. McCartney, RNC, PhDKristen Montgomery, RN, PhD

Anne A. Moore, RNC, MSNDianne Morrison-Beedy, RNC, WHNP, PhDMary R. Nichols, RN, CS, FNP, PhDSusan A. Orshan, RNC, PhDCynthia Persily, RN, PhDKathie Records, PhD, RNMichelle Renaud, PhD, RNCyndi Roller, WHNP, CNM, PhDPatsy Ruchala, RN, DNScRebecca B. Saunders, RNC, PhDJan Sherman, RN, NNP, PhDMartha Sleutel, RN, PhD, CNSLinda Snell, WHNP, DNSMary Ann Stark, RNC, MSLynn Stover, RN, DSNMarilyn Stringer, PhD, CRNP, RDMRosemary Theroux, RNC, MS, PhDLorraine Tulman, DNSc, RN, FAANLeona VandeVusse, CNM, PhD, FACNMVictoria von Sadovsky, PhD, RNCandy Wilson, RNC, MSNJeanne Wilton, RNC, MS, IBCLC, WHNPMargaret R. Wood, RN, PhD

JOGNN Reviewer Panel: 2004

childbearing women's perceptions of nursing care that promotes dignity

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