Coherent childbearing

Background: Over the last 10 years, Australia's spontaneous vaginal birth rate has decreased approximately 1% each year and the caesarean section rate has increased approximately 1% each year. This trend has serious implications for the health of women and babies. As midwives we are the caretakers of normal birth and therefore partly responsible for its decline and the solution to its decline. Although antenatal education is in a potentially powerful position to promote normal birth, a structured review conducted as part of this thesis found that it does not realise that potential. Currently framed in pathogenesis, antenatal education in particular and maternity services in general, are in need of reframing. The theory of salutogenesis may offer a new lens as it focuses on health rather than illness. Sense of coherence is the cornerstone of salutogenesis and is a predictive indicator of health. What is unclear is the role pregnant women's sense of coherence plays in their birthing outcomes. This study explored associations between pregnant women's sense of coherence, their pregnancy choices, their anticipated labour choices, their labour and birthing outcomes as well as factors associated with modification to sense of coherence from the antenatal to postnatal periods. Methods: After a comprehensive review of the literature, questionnaire development and psychometric tool testing and modification, a longitudinal survey was conducted where eligible women completed a questionnaire before the 30th week of pregnancy (Phase One) and approximately 8 weeks after birth (Phase Two). Eligible women were less than 30 weeks pregnant with a single fetus, could read and write in English and lived in the Australian Capital Territory in Australia. Phase One provided information on women's sense of coherence scores, Edinburgh Postnatal Depression Scale (EPDS) scores, Support Behaviour Inventory (SBI) scores, pregnancy choices including care proVider, planned place of birth, planned birth type and anticipated epidural use and demographics. Phase Two provided information on women's sense of coherence scores, EPDS scores and their labour and birthing outcomes. Findings: 1074 women completed Phase One representing a 61.3% response rate. 753 women completed Phase Two representing a 70.1% retention rate between phases. Compared to women with low sense of coherence, women with high sense of coherence were older, reported fewer pregnancy conditions such as diabetes or hypertension, were less likely to have depressive symptoms, were more likely to feel well supported, were less likely to experience a caesarean section and more likely to experience an assisted vaginal birth. Sense of coherence was not associated with women's pregnancy choices. Higher EPDS scores, lower sense of coherence and greater satisfaction with birth were associated with an increase in women's sense of coherence from the antenatal to the postnatal period. Decreased birth satisfaction and experiencing epidural anaesthesia in labour and assisted vaginal birth were associated with a decrease in sense of coherence from the antenatal to the postnatal period. Conclusion: Strong sense of coherence in pregnant women halved the likelihood of experiencing caesarean section compared to women with low sense of coherence. Sense of coherence is a modifiable predictor of women's childbearing health and was found to be raised by birth satisfaction and lowered by birth dissatisfaction and labour interventions. These important findings add to the limited body of knowledge about sense of coherence and childbearing.