Special issue on cross‐national comparisons of psychosocial aspects of childbirth

Most research is carried out within a single country, and that applies to psycho‐social aspects of childbirth as much as other fields of enquiry. We have learned a lot from such studies. However, there is always the danger that our conclusions are not made at the right level of generality. Almost certainly, our perceptions and interpretations are limited by the setting in which our research was carried out, the ways in which questions were asked and the cultural norms that govern people's responses. To understand more about these issues, ideally, we need to gather data in more than one country. The aim of this Special Issue was to draw together not only studies which had cross‐national comparison as their focus, but also to encourage collaborative secondary analysis between researchers who may have carried out similar studies in different countries. Contributors were particularly invited to describe and discuss methodological issues that had arisen in attempting to carry out such research (e.g. organisational issues; availability of different types of data; different contexts for recruitment). These issues therefore receive relatively more attention than is often the case in other journal articles.

The majority of studies presented in this Special Issue managed to avoid some of the most difficult methodological artefacts by carrying out studies in two different countries using the same data collection materials (Baston et al; Kjærgaard et al; Christiaens et al, Hellmers & Schuecking; Bielawska‐Batorowicz & Siddiqui). Nevertheless, even these studies found themselves open to a number of methodological limitations; for example, because data were not collected at the same time or because different maternity care systems and research governance requirements made it impossible to recruit truly comparable samples. These are issues that could arise even in a planned cross‐national study and it is of considerable value to have them raised here. The smaller studies especially illustrate the difficulties inherent in trying to ensure that samples are truly comparable and the authors have been encouraged to tell us about the challenges and limitations so that we can all be aware of the pitfalls.

The seeds of this Special Issue were sown at a small meeting of maternity researchers in Osnabrueck in July 2007. We had met to discuss the possibility of a large cross‐national study of women's childbirth experiences. We were motivated by the knowledge that obstetric and midwifery practices vary considerably from country to country and that recent large‐scale studies of women's experiences (Declercq, Corry, Applebaum, & Risher, 2002; Declercq, Sakala, Corry et al., 2006; Redshaw, Rowe, Hockley, & Brocklehurst, 2007) were indicating some striking commonalities as well as differences. Inevitably, though, these studies had used different data collection tools and different methods and it is therefore not easy to say to what extent findings are truly comparable.

The ideal cross‐national study will take a great deal of planning, and will be expensive to carry out, and it will therefore be some years before we can be in possession of its findings. Meanwhile, we felt both an academic and an ethical imperative to make further use of data that were already in existence. One direct result of that is the paper in this issue by Schytt and colleagues who were able to combine data from the national ‘KUB’ study in Sweden (N = 3113) (Schytt, Lindmark, & Waldenstrom, 2004) and the somewhat smaller ‘Greater Expectations?’ study (N = 1439) (Green, Baston, Easton, & McCormick, 2003) in England. Their paper is presented as a worked example of the frustrations and limitations of such an approach. It does, nevertheless, present us with some challenging findings and pointers for further research. For example, Swedish women were much more positive about both themselves and their caregivers during labour. Do these represent genuine differences in experiences, cultural differences in ways of responding or methodological artefacts? These are fundamental questions that any cross‐national study has to grapple with. However, communication during labour has recently been highlighted as a key issue in the Intrapartum Care Guidelines issued by the National Institute for Health and Clinical Excellence (NICE) in the UK (2007). These results suggest that Swedish midwives may in fact be communicating in ways which make women feel better about themselves and which are associated with better clinical outcomes. If this is indeed the case, then this an area justifying further detailed study.

The paper by Declercq and Chalmers draws on two very large national surveys and is able to show us how two neighbouring countries with very different care systems can lead to interesting differences in women's experiences, as well as some marked similarities. Similarly, Christiaens et al. focus on two neighbouring countries, Belgium and the Netherlands, which are similar in many ways, but have very different maternity systems. The Dutch system is renowned for its high level of home births and a non‐interventionist policy, and it has tended to be assumed that this is associated with more positive psychosocial states for Dutch women. This assumption receives a major challenge both from Christiaens' study and from that by Baston et al. conducted in England and the Netherlands. Christiaens' design is able to control for planned and actual place of birth and to examine expectations as well as outcomes. Baston et al., looking back on the birth some years later, are able to focus on the factors which are associated with a negative appraisal in the two systems of care. They find that emergency caesarean and instrumental birth; feeling that the baby's life had been in danger; negative perception of the staff; and major health problems since the birth were predictors in both countries and that, contrary to their hypothesis, an emergency caesarean did not have a more negative impact on Dutch women than on those in England. Indeed, they found that more Dutch women were negative looking back, whatever their mode of birth. These two studies are important not only for those involved in the provision of maternity care in the Netherlands, but for all of us who wish to understand more about psychosocial aspects of childbirth.

The remaining papers in this special issue are smaller‐scale studies with a more specific focus: fear of childbirth (Kjærgaard et al.); preferred mode of birth and antenatal emotional wellbeing (Hellmers & Schuecking) and prenatal attachment (Bielawska‐Batorowicz & Siddiqui). Kjærgaard et al. find no difference in fear of childbirth between women in Sweden and in Denmark and also find that a woman's level of fear is apparently unaffected by the discovery that the midwife who will care for her in labour is someone that she already knows. Hellmers and Schuecking's study looked at three useful validated instruments (WHO‐5 Well‐Being Index [WHO, 1998], Sense of Coherence Scale [Antonovsky, 1987] and Edinburgh Postnatal Depression Scale [Cox et al., 1987]) in the context of women's preferences for mode of birth in Germany and in the USA. Very few pregnant women in either sample preferred to deliver by caesarean section, but there was a relationship between women's well‐being, women's sense of coherence and the preferred mode of birth in the German sample. Their findings on the relationship between the WHO‐5 Well‐Being Index and the Edinburgh Postnatal Depression Scale need to be followed up in future research. Bielawska‐Batorowicz and Siddiqui examine prenatal attachment in samples of Swedish and Polish women and find broad similarities but also some suggestions of differences both in the aspects of attachment and in interactions with independent variables. These differences are discussed within the contexts not only of maternity care provision but also of normative attitudes towards motherhood which may shape women's responses.

Three of the papers in this issue (Schytt et al.; Kjærgaard et al.; Hellmers & Schuecking) are limited to first‐time mothers, while the others cover women of all parities. This is a very important dimension in research in this field which is not always given due attention. Not only are obstetric intervention rates much lower for women on their second and subsequent pregnancies, but their prior experience is a major factor in shaping their hopes and expectations for the birth to come. This is evident from large studies like KUB and Greater Expectations?, and would appear to be true across different countries. First birth is frequently associated with a negative birth appraisal (e.g. Waldenstrom, Hildingsson, Rubertsson, & Radestad, 2004). This is supported here in the study of Baston et al., where in the Dutch sample first birth was found to remain as an independent predictor of a negative appraisal even when mode of birth and other interventions were taken into account.

This special issue represents the experiences of women in Belgium, Canada, Denmark, England, Germany, the Netherlands, Poland, Sweden, and the USA and thus covers a very wide range of maternity practices available to women in developed countries. It is our hope that, individually and collectively, they will allow us new insights into important aspects of women's experiences of childbirth.