Conduct a literature search to locate a journal article related to the health or health care practices of Irish people and childbirth. Present a summary of the journal article, and examine how the information presented may impact your nursing practice. Please provide a copy of the journal article (or hyperlink) if possible: 400 words 

Hunter, A., Devane, D., Houghton, C., Grealish, A., Tully, A., & Smith, V. (2017). Woman-centred care during pregnancy and birth in Ireland: thematic analysis of women’s and clinicians’ experiences. BMC pregnancy and childbirth, 17(1), 322. https://doi.org/10.1186/s12884-017-1521-3

RESEARCH ARTICLE Open Access

Woman-centred care during pregnancy and
birth in Ireland: thematic analysis of
women’s and clinicians’ experiences
Andrew Hunter1*, Declan Devane1, Catherine Houghton1, Annmarie Grealish2, Agnes Tully1 and Valerie Smith1

: Recent policy and service provision recommends a woman-centred approach to maternity care. Midwife-
led models of care are seen as one important strategy for enhancing women’s choice; a core element of woman-centred
care. In the Republic of Ireland, an obstetric consultant-led, midwife-managed service model currently predominates and
there is limited exploration of the concept of women centred care from the perspectives of those directly involved; that
is, women, midwives, general practitioners and obstetricians.
This study considers women’s and clinicians’ views, experiences and perspectives of woman-centred maternity
care in Ireland.

: A descriptive qualitative design. Participants (n = 31) were purposively sampled from two
geographically distinct maternity units. Interviews were face-to-face or over the telephone, one-to-one or
focus groups. A thematic analysis of the interview data was performed.

: Five major themes representing women’s and clinicians’ views, experiences and perspectives of
women-centred care emerged from the data. These were Protecting Normality, Education and Decision
Making, Continuity, Empowerment for Women-Centred Care and Building Capacity for Women-Centred Care.
Within these major themes, sub-themes emerged that reflect key elements of women-centred care. These
were respect, partnership in decision making, information sharing, educational impact, continuity of service,
staff continuity and availability, genuine choice, promoting women’s autonomy, individualized care, staff
competency and practice organization.

: Women centred-care, as perceived by participants in this study, is not routinely provided in
Ireland and women subscribe to the dominant culture that views safety as paramount. Women-centred care
can best be facilitated through continuity of carer and in particular through midwife led models of care;
however, there is potential to provide women-centred care within existing labour wards in terms of
consistency of care, education of women, common approaches to care across professions and women’s
choice. To achieve this, however, future research is required to better understand the role of midwife-led care
within existing labour ward settings. While a positive view of women-centred care was found; there is still a
difference in approach and imbalance of power between the professions. More research is required to
consider how these differences impact care provision and how they might be overcome.

Keywords: Women-centred care, Choice in childbirth, Qualitative enquiry, Framework analysis, Thematic analysis

* Correspondence: andrew.hunter@nuigalway.ie
1School of Nursing and Midwifery, National University of Ireland, Galway,
Galway, Ireland
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Hunter et al. BMC Pregnancy and Childbirth (2017) 17:322
DOI 10.1186/s12884-017-1521-3

http://crossmark.crossref.org/dialog/?doi=10.1186/s12884-017-1521-3&domain=pdf

mailto:andrew.hunter@nuigalway.ie

http://creativecommons.org/licenses/by/4.0/

http://creativecommons.org/publicdomain/zero/1.0/

Background
Internationally, the last 15 years have seen policy makers
and service providers recommend that maternity services
become more woman-centred [1–3]. A key component of
these recommendations is the promotion of additional
models of maternity care including midwife-led models of
care which are seen as one important strategy in enhan-
cing women’s choice, a key component of woman-centred
care (WCC). In the Republic of Ireland (ROI), however,
choice in models of maternity care has not kept pace with
that evident in services in other high income countries.
Currently, an obstetric consultant-led, midwife-managed
service model predominates [4]. This model involves the
vast majority of women giving birth in urban maternity
hospitals, including over one-third of all women giving
birth in one of three urban maternity hospitals, under the
lead care of a consultant obstetrician with midwives. It is
hoped however that Ireland’s first national Maternity
Strategy [5], published recently on foot of significant
shortcomings in Irish maternity services, will offer more
choice of quality models of maternity care to women and
their families.
In the United Kingdom (UK), reports into the nature of

maternity services in the 1990s [6–8] resulted in a change
of emphasis towards WCC. This policy driven change di-
rected service providers to engage with and meet the
needs of women, placing them at the centre of planning
and evaluation maternity services. In the ROI, the absence
of a cogent national maternity strategy has, until recently,
facilitated the continuation of a largely singular model of
maternity care, that is, a consultant-led, midwife-managed
service [9]. Consequently, there has been limited develop-
ment of midwife-led models of maternity care other than
small, albeit important, isolated clusters including the es-
tablishment of two midwife-led units [10]. The ROI con-
tinues to offer an obstetrician led approach to care similar
to the approaches in Iran and Lebbanon [11]. This is in
spite of a growing body of evidence from other high in-
come countries such as the UK, France, Australia and
New Zealand where evidence led alternative approaches
such as midwife-led continuity of care have been adopted
[11]. Implementation of midwife led approaches empha-
sizing WCC have been shown to offer equivalent levels of
safety with the added benefit of giving women more
choice resulting in more positive pregnancy, birth and
post-natal experiences [10, 11].
The recent National Maternity Strategy (2016) calls for

an increased choice in models of maternity care in Ireland
[5]. One clear barrier to change is a lack of clarity on stake-
holders (women and clinicians) understanding and know-
ledge of what constitutes WCC, and a lack of evidence that
gives a qualitative voice to women’s views, experience and
preferences while availing of current maternity services [10,
11]. For this reason, there is a need to describe the core

attributes or indicators of WCC during pregnancy, birth
and postnatally in Ireland, from the perspective of all stake-
holders; that is, women, midwives, general practitioners
and obstetricians, and, in doing so, achieve a better under-
standing of WCC which will provide an important founda-
tion for developing strategies for change.

Methods
Aim
The aim of this study was to explore the concept of
WCC during pregnancy and birth within the Irish con-
text, and, through women’s and clinicians’ views, experi-
ences and perspectives, identify the key elements of
WCC so that it might be better understood.

Study design and setting
A descriptive qualitative study design was chosen as the
most appropriate design to address the research aim.
This design presents and interprets participant data in a
rigorous and clear manner [12] utilizing methods best
suited to the area of interest. In this instance, data were
collected via face to face or telephone interview and
focus group. Framework and thematic analysis were then
utilized to analyze the data. To explore potentially com-
mon and unique manifestations of WCC, two geograph-
ically distinct maternity units were chosen from which
to access the stakeholder groups. These were a large
urban maternity hospital (circa 8000 births per year) and
a regional maternity hospital (circa 4000 births per year),
both with similar philosophical and organizational ap-
proaches, that is predominantly consultant-led, midwife-
managed care, with, to a lesser extent, embedded or
alongside midwife-led care.

Ethics
Ethical approval for the study was granted by the re-
search ethics committees of the two participating hospi-
tals. Written consent to contact was obtained by the
gatekeepers and participant contact details were for-
warded to the interviewer who subsequently contacted
participants to arrange a suitable date, time and venue
for the interview. The purpose of the research was fur-
ther explained to all prospective participants, including
potential benefits and harms, and, they were asked if
they were willing to take part. All participants being
interviewed provided written consent prior to commen-
cing the interview.

Sampling and data collection
The participants (n = 31) were purposefully sampled
from diverse stakeholder groups (Table 1), providing a
range of perspectives and knowledge of WCC. Two mid-
wives, working at the study sites, acted as gatekeepers,
and assisted with the recruitment process by advertising

Hunter et al. BMC Pregnancy and Childbirth (2017) 17:322 Page 2 of 11

the study locally, by distributing the study information,
verbally and in written format, and by discussing the
study further with eligible participants. Although the
study did not seek to compare models of maternity care
or views/experiences of different models of maternity
care directly; participant perspectives on what does or
does not comprise WCC across the available settings
(consultant-led care only, midwifery-led care only, and
consultant and midwifery-led care) was purposively
sought so as to ensure stakeholders working in the vari-
ous settings were represented in our study sample. The
majority of participants were interviewed individually, in
person or by telephone, by the same researcher (VS).
Focus group interviews were conducted with single pro-
fessional groups; that is, two focus groups with midwives
(n = 4) only and one with GP participants only (n = 5).
This approach was necessary for reasons of access, logis-
tics and practicality. Collecting interview and focus
group data arising from discussion amongst participant
groups added to the variation and depth of the overall
data. The mean interview duration was 32 min (range
21–45 min). All efforts were made to ensure participa-
tion from all members of the groups and the focus
group participants were asked the same questions as the
individual interview participants, thus ensuring a prag-
matic and consistent approach to data collection [12].
To ensure baseline consistency across interviews and
groups, an interview schedule, based on four broad
questions, was used to guide the information sought.
These broad questions were (i) what do you understand
by women-centred maternity care?; (ii) what do you
think are the important components of women-centred
maternity care?; (iii) what things can/do maternity ser-
vices do that engenders women-centred maternity care?;
and, (iv) what things should maternity services avoid or
minimize in promoting women-centred care?

Qualitative data analysis, following verbatim transcrip-
tion of the interviews and focus groups, was conducted
by a team of four researchers (AH, CH, AG, AT) who
were not involved in conducting the interviews. All of
these researchers are nursing academics and have per-
sonal experience of the Irish maternity care system. All

interviews were audio recorded, anonymized to ensure
confidentiality and transcribed verbatim by professional
transcribers and checked by the research team for accur-
acy. Thematic analysis was used incorporating a frame-
work analysis approach [13]. Framework analysis [14]
has five key stages (familiarization; identifying a thematic
framework; indexing; charting & mapping and interpret-
ation). The first two stages were used in this analysis to
help guide the analysis team, that is, familiarization and
identifying a thematic framework.
Familiarization involved two members of the team de-

veloping coding themes from two of the transcripts in
order to become familiar with the data. In stage two, all
four members of the team then coded a single transcript
using the framework. This process allowed the team to
acknowledge their own personal perspectives, modify
the framework and develop inter-coder agreement. Cod-
ing stripes within NVivo were used to determine the
level of agreement between team members [15]. This
process allowed comparison, discussion and agreement
of the framework for stage three.
In the third stage of analysis, each team member

was assigned a number of transcripts to code. Anno-
tations were used to document researcher questions,
decision about the data, reflections on analysis and to
provide a clear audit trail of the process. The themes
and their titles were subject to restructuring from the
original framework as similarities and differences were
identified allowing accurate representation of what
participants were saying (see Table 2). At this stage,
NVivo was utilized to apply query tools to check the
accuracy of the themes and associated memos. The
final stage of analysis involved using executive sum-
mary statements as the foundation for drafting the re-
sults that described the views, perceptions and
experiences of women, midwives, obstetricians and
GPs on the concept of WCC.

Table 1 Study Participants

Participant Type Number (Site 1/Site 2)a

Women (postnatal) 11 (4/7)

Midwives 10 (5/5)

Obstetricians 5 (2/3)

General Practitioners 5 (1 GP practice)
a Site 1 = urban maternity hospital; Site 2 = regional maternity hospital
The interviews were conducted from January to April 2015

Table 2 Completed Thematic Framework

Protecting normality • Normalising
• Respect
• Public perceptions

Education and decision making • Decision making
• Information sharing
• Educational impact

Continuity • Continuity of service
• Fragmented care
• Staff continuity and availability

Empowerment for WCC • Genuine choice in WCC
• Lack of choice
• Promoting women’s autonomy
• Individualised care

Building capacity for WCC • Not providing WCC
• Staff competency
• Practice organisation

Hunter et al. BMC Pregnancy and Childbirth (2017) 17:322 Page 3 of 11

In this research, a number of strategies were used to en-
sure rigour. Firstly, triangulation was achieved through
team analysis utilizing four researchers. In addition, the
use of coding stripes within NVivo ensured inter-
researcher agreement [15]. Multiple participant types en-
sured many perspectives were captured enhancing the
completeness of the data, which is another important
element of triangulation [16]. The ability to write annota-
tions in NVivo facilitated transparent decision making
processes between the four researchers, reduced bias and
provided an audit trail supporting the results [17]. Query
tools such as matrix and coding queries were also used.
NVivo was able to locate all the passages in the data en-
suring that any themes and subsequent results could be
checked and were supported by data from more than one
individual participant [17]. Furthermore, matrix-coding
queries provided a comparison of multiple nodes as a nu-
meric table for illustrative purposes [18].

Results
Five main themes emerged from the analysis of data
within which there were sub-themes that highlighted key
elements of WCC. The five main themes were: Protect-
ing Normality; Education and Decision Making; Con-
tinuity; Empowerment for WCC; and Building Capacity
for WCC. These results describe the views, perceptions
and experiences of women, midwives, obstetricians and
GPs on the concept of WCC.

Protecting normality
This theme describes the finding from the data that
pregnancy should be viewed as a normal function, not
illness. In doing so, it reflects how respect for women
and the philosophy of WCC can help to normalize the
pregnancy journey regardless of the outcome. The sub-
themes identified were: normalizing and respect.
All participant groups identified the importance of

normalizing pregnancy and childbirth; with the nature of
the pregnancy impacting on the health care profes-
sionals’ ability to do this. For instance, it was identified
that normalizing pregnancy is more likely in midwife-led
units (MLUs) because, by their nature, the women at-
tending have more ‘straightforward’ pregnancies. A num-
ber of strategies were identified that help to normalize
the pregnancy journey. These included respecting
women’s wishes and following their birth plans. This
midwife datum represents the view that the theme pro-
tecting normality relates to giving women choice and
avoiding intervention where possible:

“The way you can do that [normalizing] is by not
doing things to women that they don’t need done to
them, you know” (Midwife-3)

These participants made an explicit link between Pro-
tecting Normality, specifically normalizing pregnancy
and having care provided in smaller more accessible set-
tings. This obstetrician participant echoes this view of
normality, identifying the need to perceive pregnancy as
a normal journey:

“And this is important for the women to understand…
that the pregnancy is not a disease, it’s not a special
condition, it’s part of the normal healthy life”
(Obstetrician-3)

This view is supported by other participants who stress
the importance of the environment in normalizing child-
birth. This midwife notes the challenge faced in provid-
ing peaceful and quiet environments in busy, and
potentially distracting, labour wards:

“You’d be trying to create the right environment so
lights really low, nice music on, the lavender going …
it’s quiet, it’s dark, it’s peaceful… Where it’s [in the
labour ward] bright lights and it’s busy and there’s
noise” (Midwife-5)

Decentralizing the provision of services was identified as
a means of protecting normality. This participant indi-
cates that it is difficult to normalize pregnancy when ser-
vices are inaccessible to women:

“If we valued women truly then we wouldn’t make
them drive sixty miles to the nearest unit” (Midwife-1)

A theme that emerged from the data and supported
the concept of protecting normality was respect: re-
spect for women, for the journey of pregnancy and
for WCC. The women participants identified that re-
spect meant being recognized as an individual with
past experiences, preferences and potential fears about
childbirth. These women participants illustrate the
importance of feeling listened to as a component of
respect:

“you’re looking after the woman as well as just the
mother of the baby …the woman is not just the mother
like you know, she’s still just you know, like a person
aside from being a mother” (Woman-2)

“Sometimes it’s nice to feel that you’re listened to and
that you’re unique” (Woman-5)

The midwife participants recognized the need for an
ethos of respect. Importantly, this did not just refer to
the outcome of pregnancy, but a respect for all stages of

Hunter et al. BMC Pregnancy and Childbirth (2017) 17:322 Page 4 of 11

pregnancy and fertility. This datum identifies the need
to establish a philosophy that normalizes and respects
WCC, with midwives themselves having a role to play in
implementing this philosophy into the care they provide:

“Midwives need to change their way of thinking to
provide the opportunity to women to have normal births
and normal birth environment. So, I sometimes find it
just a little bit frustrating that people will put up all sorts
of objections… the doctors won’t let us? When I think it’s
the midwives not letting themselves… and not standing
together. And that’s what would help achieve.. you know
normal, natural labour and birth” (Midwife-2)

Respect for the principle of WCC was influenced by a range
of societal factors, media influences and cultural beliefs
about pregnancy. Professional participants consistently
noted that a normal, safe pregnancy and birth could be ac-
commodated within a MLU, with the proviso that there is a
clear route to obstetric care and a labour ward should com-
plications arise. What became clear from the data was that
women themselves were unaware of this option due to the
prevalence of the labour ward model in Ireland:

“it’s [awareness of MLUs] not still getting out into the
community, into you know that there is another
alternative to going to have your baby in the hospital.
” (Midwife-4)

This lack of awareness of alternatives is also indicated when
participants view greater levels of medical intervention, not
only as the norm, but also as a safer option resulting in bet-
ter outcomes. These following quotes; first from a midwife
and then an obstetrician, indicate professional openness to-
wards change along with the challenge faced:

“They (women) will always want to have the most high
tech, and I think that will last for a long time, until the
service is much more balanced, and the service and
choices offered to women are more balanced. It will take
a long time for the fear factor to disappear and for the
education that comes from providing a fully rounded
service actually pervades women’s psyche and they realise
actually I don’t need every single scan.” (Midwife-1)

“Well I think I would imagine that you know if it is
explained to women what this (WCC) is, you know
what the advantages are, that they would see that.”
(Obstetrician-1)

While supportive of the principle of supporting WCC
via the introduction of MLUs across Ireland this obstet-
rician goes on to articulate the status quo regarding risk
and choice:

“There’s an assumption that something had happened,
or there’s bad publicity, or that you feel safer in going to
urban. You know so it was seen as a continuum, and
that you know if you are low risk care you go to your
local hospital, the higher risk, a certain amount can be
handled in your local hospital with input maybe from
the tertiary centre, and then you have people who need
the tertiary level care, full stop.” (Obstetrician-1)

In summary, protecting normality identifies that participants
believe pregnancy and childbirth can and should be per-
ceived as normal, also that there should be a minimum of
intervention in support of this normality. While all of the
participant groups aspired towards this they were also clear
that the current systems with emphasis on safety and the
timely processing of women in labour wards meant that
there would need to be significant change if normality is to
be re-instituted in the face of near ubiquitous medical inter-
vention. Inherent in any approach to protecting normality is
the need to educate women and respect women’s primacy in
decision making during pregnancy via a WCC philosophy.

Education and decision making
The education and decision making theme describes how
professional training impacts upon professionals’ educa-
tion of women, affecting the decisions made across the
journey of pregnancy. This theme brings together three
sub-themes that emerged from the data: partnership in
decision making; information sharing and educational im-
pact. There was considerable agreement amongst the par-
ticipants regarding the need to improve the education of
women regarding their care options. The professional par-
ticipants indicated that providing better quality education
to women could improve the overall quality of WCC. Pro-
fessional participants also provided examples of where
their own education required improvement to allow more
skilled educational support for women and to improve
inter-professional understanding.
The sub-theme partnership in decision making reflects

the understanding that WCC requires the provision of
genuine choice through education, which can only be
provided when stakeholders have knowledge regarding
care options and when such care options are actually
available. A view illustrated by this GP participant who
noted the need to educate women on their options:

“if you empower them (women) with all the
information…, risks and benefits of certain treatments
and ultimately you know, if they’re well informed,
women can make their own decision about what kind
of management they want. So I guess it’s trying to give
them all the information so they can make decisions
themselves about their own management. ” (General
Practitioner-5)

Hunter et al. BMC Pregnancy and Childbirth (2017) 17:322 Page 5 of 11

The information sharing sub-theme describes the need
for and potential benefits of professions improving un-
derstanding of each other and being educated in each
other’s approaches to care. This midwife participant
makes the case for different stakeholders having a com-
mon skill set:

“we need to introduce something called an obwife
(laugh) instead of an obstetrician in isolation, not a
midwife, maybe an obwife… I think the problem is
nobody is the enemy here, the obstetrician is not the
enemy, the women, the midwife is not the enemy but
the poor woman should not fall between 2 egos. The
women should get the care based on the best.”
(Midwife-10)

This datum reflects the view voiced across participant
types that there was a need for greater inter-professional
understanding and emphasis on a shared ethos of WCC.
The educational impact sub-theme provides additional
understanding by relating the information women are
given to professional knowledge, organizational systems
(in the example below whether the woman was consist-
ently seen and comprehensively assessed) and individual
confidence to provide individualized rather than generic
advice. This midwife participant illustrates the range of
components that must be in place along with education
to ensure that decision making is woman-centred:

“co-sleeping is one example, I would find it very hard to
say to a mother not to co-sleep with her baby in the first
8 weeks. But as a professional I have to be aware of giv-
ing her the correct information. And I think currently
the correct information is not to co-sleep. But I would
find that very hard. But I cannot do a disservice to the
woman because I don’t know if her bed is big enough. I
don’t know if her home is properly heated, if her partner
or herself smokes or takes recreational drugs or takes
any prescribed medication.” (Midwife-1)

The theme education and decision making represents
the finding that professionals need to develop their own
knowledge, along with developing a shared ethos of
pregnancy and child birth. The lack of a shared ethos is
currently viewed as limiting choice by women and for
women and as a barrier to WCC. Raising inter-
professional knowledge was viewed as a means of enhan-
cing access to other models of care as trust between the
professions was seen as a requirement for change.

Continuity
The theme continuity brings together three sub-themes:
continuity of service, fragmented care, and staff continu-
ity and availability. Firstly, continuity of service, relates

to the importance of having not only continuity of care
during pregnancy but also in labour and in the post-
natal period. Consistency of clinician over the term of
pregnancy, that is, continuity of carer, was considered
synonymous with good quality care. One obstetrician
interviewed noted that women express dissatisfaction
with hospital services where women tend to see different
doctors, and do not view themselves as being offered
care by a consistent team:

“…if we could manage to be a little more consistent
regarding who is getting seen, or that there is a smaller
group of people that might see the woman, so that she
is getting the impression that she’s been seen by a team
rather than by nobody in particular. ..I think that’s
about consistency”. (Obstetrician-1)

All participants noted that MLUs provide greater con-
tinuity of carer. This midwife participant, based in a
labour ward, articulates their view of continuity as a po-
tential benefit of a MLU service:

“if you look at other models of care then like midwife-
led clinics, maternity, midwife-led units, where you
have smaller teams, you have a chance of obtaining
continuity of carer” (Midwife-7).

The sub-theme, fragmented care, extends the under-
standing of the implication of inconsistent service
provision. This GP participant notes how different
professionals are involved in caring for the pregnant
woman and how they tend to work parallel to rather
than communicating effectively with each other. In
this example, they view failures in communication as
fragmentation:

“[I have] had patients who, em, have attended a
hospital with a miscarriage but haven’t come through
you so you’re not aware and then they arrive in a
couple of weeks later and you say oh you’re in for your
check-up. And they say well actually no” (General
Practitioner-5).

This midwife views service fragmentation as a feature of
having three layers to the perinatal service; antenatal,
labour and postnatal care:

“the current service does an awful lot to prevent
continuity of care, in terms of… the organization of our
services, we have antenatal, we have labour ward, we
have postnatal, we have fragmented what is a
continuous process of pregnancy…if you look at
obstetricians, midwives, GPs, public health nurses…we
all function again almost independently or separately

Hunter et al. BMC Pregnancy and Childbirth (2017) 17:322 Page 6 of 11

from each other… So the first thing you have to do is
prioritize it, because all the literature would say it was
important” (Midwife-6).

The staff continuity and availability sub-theme emphasized
the importance of relationship building between women
and professionals. These midwife participants viewed this
as maintaining the woman at the centre of care:

“[The MLU is] excellent in involving women a lot more
and I think the fact that they tend to see the, say
midwife, or generally speaking see the same midwife
for each hospital visit has been huge… they seem to
discuss a lot more, and they seem to develop a very, or
foster a very good relationship between the midwife
and the, the woman” (General Practitioner-5)

The continuity theme highlights the need for women to
have ease of access to services, good communication be-
tween service providers and consistent contact between
women and staff. In practice, much care is noted to be
fragmented with care being received in parallel and lim-
ited communication between primary care, hospital ser-
vices and MLUs.

Empowerment for WCC
This theme illustrates how empowerment is viewed as a
precursor of WCC and was valued highly and regarded
as important for women across the pregnancy journey.
This theme also describes how empowerment can have
an impact on women’s choice and autonomy. This
theme comprises four main sub themes; that is, genuine
choice in WCC, lack of choice, promoting women’s au-
tonomy, and individualized care. There was considerable
consensus amongst the participant groups regarding the
importance of choice and how this could be facilitated
but the data also indicated the lack of choice and result-
ant lack of WCC.
The sub theme, genuine choice in WCC, describes

how resources in maternity care are linked with lack of
choice in the birth plans and flexibility in terms of loca-
tion of care. This woman participant highlights the con-
flict between existing service provision and a woman
focused service offering more choice:

“I suppose its focusing on the woman’s care and the
baby as opposed to what a clinical led care, you know
you’d have a say in what you would like, you know
what women would want themselves for their
maternity, what they feel, I presume that’s what it
means”. (Woman-3)

The sub theme, lack of choice, describes how limited the
services are when it comes to flexibility and how

participants identify that enforced changes to daily rou-
tine are also related to lack of choice:

“And even the diabetic ladies coming in and they say
well I don’t usually take my insulin till ten when I’m
at home. But they’re getting their breakfast at eight
o’clock here and then they’re saying their blood sugars
are out because she’s not in her normal routine”.
(Midwife-10)

The sub-theme ‘promoting women’s autonomy and em-
powerment’ describes the participants’ experiences of
power, control, knowledge and their influence upon in-
formed decision making. The participants provided ex-
amples of the importance of listening, partnership
working and shared decision making which places
women at the centre of their care:

“…you go for your antenatal visits and you’re kind of
like powering through the system in five minutes and
out the door again, you’re kind of, you walk by feeling
there’s no one really listening to you, you don’t feel they
care……. you know it would be nice to have that sort
of, feeling that someone actually is listening to you and
kind of cares what happens to you, it’s the woman as
well not just the baby”. (Woman-5)

The final sub theme ‘individualized care’ describes how
important communication is in sharing of information
and partnership working, and providing emotional and
practical support in order that informed choices can be
made. This was strongly stated by the women partici-
pants, with the following two quotes illustrating different
aspects of ‘individualized care’:

“I suppose it’s because you’ve never looked after, a
hundred percent of the time, a newborn infant before,
so it just gives you a heads-up, and they show you how
to care, how to bathe a newborn, how often to feed
them. Nothing can prepare you for holding that new-
born in your arms, but it does go some way towards
helping. And as well you get to meet other women who
are in the same boat as you, and you get to, you know,
chat with them as well”. (Woman-1)

“And they were saying relax, everything is fine, you’re
doing perfect, you’re doing great. And they just talked
me through so, it was just the easiest labour I ever had
with this specific midwife I had at that time. And that
was definitely woman centred care. You know she was
there with me, she was talking through with me, you
know she was telling me everything was fine, we’re
here, we have everything, you know don’t worry,
nothing else is going to fall out (laugh)”. (Woman-5)

Hunter et al. BMC Pregnancy and Childbirth (2017) 17:322 Page 7 of 11

The theme Empowerment for WCC describes how pro-
viding a woman with choices is a key principle of mater-
nity care and the lack of empowerment diminishes
WCC. All of the participant groups were generally crit-
ical of the failure of services to empower women in
current Irish maternity services. Participants identified
limited resources, lack of choice over location of care,
and clinician’s’ application of rule structures within the
services as inflexible, hierarchical and disempowering to
both women and professionals. This theme also repre-
sents a consensus between the participant groups on the
importance of individualized care, the need for better
communication, sharing of information and partnership
working. Empowerment may also be enhanced by pro-
viding emotional and practical support to facilitate in-
formed choice.

Building capacity for WCC
The theme building capacity for WCC describes how the
data indicated that WCC can be developed and main-
tained. This theme comprises three main sub-themes:
not providing WCC, staff competency and practice
organization. Participant data indicated some instances
where WCC was achieved, with the majority of the data
indicating a lack of capacity for WCC.
The sub-theme, not providing WCC, describes how

limited resources in maternity care, linked with existing
ways of working, impact negatively on overall capacity
to provide WCC. This links building capacity for women
WCC with other themes specifically continuity as illus-
trated by this GP datum:

“They’re kind of having to retell their story I think
each time that they go in for this (outpatient
appointments). There’s a lack of continuity there I
think”. (General Practitioner-2)

These data are consistent with other data indicating a
preference for, but lack of continuity of carer. The data
also demonstrates that the organizational structure and
emphasis on safety within stretched labour ward envi-
ronments limits WCC:

“one midwife to fourteen mums and fourteen babies, if
you eventually get to the stage where you can mention
anything about those things [general care such as
varicose veins or sciatica], then you are doing amazing
in that environment. So, yea, I think the art is getting
squashed out for us, and we could do more for women”
(Midwife-1)

The second sub-theme, staff competency, refers to the
ability of professionals to work with women in a manner
that provides a range of choices. Communication, both

with women and inter-professionally is shown to impact
upon the provision of WCC. This midwife datum sug-
gests that where there is a lack of common ethos and
understanding between the professions, particularly ob-
stetricians and midwives, it can impact on quality of care
reducing WCC:

“nobody is the enemy here, the obstetrician is not the
enemy, the women, the midwife is not the enemy but
the poor woman should not fall between 2 egos. The
women should get the care based on the best evidence.”
(Midwife-4)

While organization and resources are often noted as
impacting on capacity, staff experience is also indicated.
This midwife participant notes that individual experi-
ence, professional knowledge and confidence can add to
the potential for WCC to occur:

“But then you know the levels of experience and what
levels then do you allow to make those decisions,
would be up for, that’s another discussion in itself, who
makes the final management plan? Because like you
might have someone who has years of experience and
they have the knowledge that they can push a woman
that bit further in order to maintain normality and a
safe outcome. As opposed to someone else who might
be having fear of well we can’t push her, let’s deliver”
(Midwife-6)

In addition, analysis of these data indicate that WCC
arises from the capacity to provide women with a range
of informed choices. Importantly, these choices need to
be underpinned by common ethos and capacity across
professions, as summed up by this datum:

“And like that I don’t feel that it’s always going to be
midwifery based, someone with a history of two previous
sections, knows she’s not going to have a normal delivery.
But what’s the safest way for her; I think it’s about safety
and informed choice” (Midwife-6)

An opposing view is presented by this obstetrician par-
ticipant who suggests that women’s choice is and should
be limited on practical grounds:

“So if you are too liberal with the woman deciding the
choice, it’s hard to work it (an outpatient clinic) in the
way that our system works currently” (Obstetrician-1).

That the obstetrician refers to ‘current’ systems reflects
the understanding, prevalent within the data, that achiev-
ing WCC will require significant change and investment.
The final sub theme, practice organization, describes how

Hunter et al. BMC Pregnancy and Childbirth (2017) 17:322 Page 8 of 11

current organizational structures can serve to diminish or
enhance WCC. This midwife compares public and private
care suggesting that private care can offer more continuity
and therefore be more woman-centred:
I believe that women, a lot of women, they buy private

maternity care, they probably do it to get a certain amount
of nicer accommodation, even during the pregnancy, less
waiting times – but they buy continuity of carer. And that
must be extraordinary for them to be able to go to the
same person again and again and again. And the sad thing
about our services is you have to pay for it out of your
own pocket, every woman should have the chance of that
within the public healthcare system. (Midwife-2).
The idea that current labor ward organizational envi-

ronments reduce capacity for WCC is also referred to in
terms of staff-woman interaction. The ratio of midwives
to women and the ethos of ensuring rapid turnover is
referred to regularly in the data:

“When you’re in you’re in and out in 5 and 10
minutes. However if you attend a midwifery led clinic
you know there might be, let’s say 15 women attending
one midwife as opposed to 140 women attending 3
obstetricians. And like midwives will give women time
and give them the opportunity to ask questions and all
of that” (Midwife-5)

In summary, building capacity for WCC describes how
WCC is currently negatively impacted by a range of fac-
tors including organizational structures, professional dif-
ferences in ethos, experience and skills. While this data
is largely negative, there is a common view that there is
a need to raise capacity, specifically the degree to which
women are offered choice in models of maternity care
and continuity of carer.

This study set out to explore the views and experi-
ences of women and clinicians of WCC during preg-
nancy and childbirth in the ROI so that key
elements of the concept might be highlighted and
better understood. The analysis indicates themes that
could potentially inform the achievement of WCC.
The interaction of these themes: protecting normal-
ity, education and decision making, continuity, em-
powerment for WCC and building capacity for WCC
indicate strategies towards WCC. These identified
themes resonate, in part, with findings from previous
studies on WCC. For example Maputle and Donavon
[19], in their concept analysis of WCC, identified in-
formation sharing and empowerment as key attri-
butes of WCC. They also identified participative
decision-making, informed choices and autonomy,
and open communication and respect as antecedents

to WCC. Others [20, 21] assert how WCC incorpo-
rates continuity of care, control over care decisions,
and choice in all aspects of care.
The findings of this study illustrate how WCC could

potentially be achieved, but are clear that the participat-
ing professionals did not view the care they provide as
woman-centred as it ought to be/should be. In addition,
the data from women participants indicates that, while
they share preferences for some of the same constituents
of WCC as professionals, these women have little experi-
ence of a maternity service that is truly women-centred.
This finding is similar to that identified in other Irish
and international studies [10, 11, 22], that note women
often do not request, recognize or value WCC due to a
lack of knowledge. In spite of this finding all of the pro-
fessional participants indicated that the majority of
women experiencing uncomplicated pregnancies should
be offered a midwife led service, viewing this as a means
of enhancing WCC and providing women with choices.
The results show a continued lack of alternatives to

the prevailing obstetric consultant-led model of care
in the ROI. The professional participants indicated
that they aspired to WCC, but due to organizational
and educational challenges do not routinely provide
it. In addition, the prevailing consultant-led model of
care provided in labour wards in the ROI continues
to limit the ability of professionals to offer the full
gamut of WCC. The midwife participants indicated
the existence of a skill, power and decision making
hierarchy. This hierarchy is reinforced through an
emphasis on safety, and acts as a major challenge to
the provision of WCC. The hierarchy identified in
this study is not unique with similar results reported
in other research [23, 24]. In this study, participants
placed the decision making influence of doctors ahead
of midwives, with women themselves subordinate to
all professional decision making. Women participants,
valued some aspects of WCC such as choice and nor-
malizing childbirth, but also equated medicalized care
with normality and associated this with safety. In
practice, women participants lacked alternative nor-
malities to that of medical labour wards as they had
not given birth within any other organizational struc-
tures. Therefore, women routinely equated successful
contact with services to having a healthy baby born
under medical supervision, rather than having other
alternatives in mind or considering the overall quality
of their experience. Discussion around the policy dir-
ection of pregnancy and childbirth in Ireland [3] talks
of the ‘long road’ away from medically led and inter-
vention focused maternity care in Ireland. This study,
along with others [4, 24] considers the experience of
maternity care and childbirth in the ROI, and indi-
cates that the long journey continues.

Hunter et al. BMC Pregnancy and Childbirth (2017) 17:322 Page 9 of 11

Strengths and limitations
This study is strengthened by the inclusion of multiple
stakeholder groups (women, midwives, obstetricians and
GPs) and aggregating data from interviews and focus
groups, thus offering varying perspectives and know-
ledge of WCC for informing the collective results. The
inclusion of stakeholders from two hospital locations
may have limited the overall findings, however, we be-
lieve this was minimised by choosing diverse study sites,
that is one urban and one regional, where care, in the
main, is reflective of mainstream Irish maternity care.
Similarly analysis of data derived from different methods
may have limited the findings, however we believe it
provides a depth of aggregated collective findings based
on variation in data collection methods.

Implications for practice and research
There is now a body of research evidence and policy guid-
ance calling for change in the manner in which pregnancy
care and childbirth services are delivered [4, 25, 26]. In spite
of these calls, the complex hierarchical systems experienced
by all participants in this study mean that WCC is not rou-
tinely provided and technical and medical approaches to
care continue to dominate in many settings [23, 24, 26].
Research [4, 11] indicates that midwife-led models of

care can offer a service, which is, at least, as safe as other
models of care and results in in less intervention and in-
creased WCC. The results from this study support those
results that for many women WCC is best delivered via a
midwife led model of care [4, 27]. In addition to support-
ing the need to develop more MLUs in Ireland our results
indicate that there is potential to provide more WCC
within existing labour wards while moving towards MLUs.
WCC should not be the preserve of MLUs alone. In terms
of continuity of care, education of women, common ap-
proaches to care across professions and women’s choice
there is a need to shift labour ward practice towards more
WCC. To achieve this, future research must better de-
scribe and understand the role of midwife led care within
existing labour ward settings. Developing an understand-
ing of the current standard model of care would provide a
basis for change. Such an understanding could also direct
changes in midwifery care as part of moves towards
continuity orientated midwife led care within the wider
multi-disciplinary team in support of WCC. In spite of the
finding that participants in this study take a positive view
of WCC and the potential for MLUs [4, 28]. There is still
clearly a difference in approach and imbalance of power
between the professions. More research is required to
consider how these differences impact care provision and
how these can be overcome.
Understanding women’s experiences and preferences

also requires further research. As the recipients of care,
women lack awareness of alternatives to medicalized

care and their consistent view that medicalized care
equates to safety and ‘normality’ was a key finding.
Greater understanding of the impact of current care de-
livery systems, including the public-private imbalance,
on the national understanding of pregnancy and child-
birth is required to inform any changes towards WCC.
Further studies are required to provide understanding of
the degree to which women would like to be included in
the decision making process and the impact such inclu-
sion would have upon their pregnancy, birth and post
birth experience. This will require the development of
research approaches that assess women’s experience.
Such methodological developments will have to consider
the current low level of consultation and choice arising
from the lack of WCC. Therefore, future methodological
developments aimed at determining the psychosocial ex-
perience of women and impact of choice will have to in-
clude education of women in what these choices are and
their implications.

Conclusion
The results of this study indicate that irrespective of the
renewed policy, practice and research emphasis on
WCC provision as an important goal for service pro-
viders, the current reality is that WCC, as perceived by
included participants, is not experienced by most
women. In fact, the consultant-led model of care is so
much the norm in the ROI that women are largely un-
aware of the possibility of alternative approaches. Profes-
sionals, while aware of alternatives, are so burdened by
the maintenance of a safe service within an under
resourced system that improving the experience of
women via the provision of WCC will be challenging.
The recent Irish National Maternity Strategy serves as
the template for the ‘maternity workforce to … work to-
gether, in partnership across professions and with fam-
ilies, to deliver a new, better and safer maternity service’
([5] p.3).

MLU: Midwifery led unit; ROI: Republic of Ireland; WCC: Women-centered
care

We wish to thank both participating hospitals for agreeing to participate
in the study, thus facilitating access to potential participants. We also
wish to thank midwives CC and NC for assisting with recruitment
processes at the study sites. Finally, we wish to sincerely thank all of the
women, midwives, obstetricians and general practitioners who gave their
valuable time to participate in this study; without which, this study
would not have been possible.

The authors are grateful to the Health Research Board (HRB) Ireland for funding
this study. The opinions expressed here are those of the study team and are
not necessarily those of the HRB.

Subject to request from the corresponding author.

Hunter et al. BMC Pregnancy and Childbirth (2017) 17:322 Page 10 of 11

DD conceived the study. DD and VS finalized the protocol. VS conducted the
interviews. AH, CH, AG and AT analyzed the data. AH drafted the manuscript.
All authors read, contributed to and agreed the final version of the
manuscript prior to submission.

Ethical approval to conduct the study was granted by the Research Ethics
Committee of the two participating hospitals. Participants provided written
informed consent prior to being interviewed for the study.

Not applicable.

The authors declare that they have no competing interests. Author Valerie
Smith is a Section Editor for BMC Pregnancy and Childbirth.

Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.

1School of Nursing and Midwifery, National University of Ireland, Galway,
Galway, Ireland. 2Florence Nightingale Faculty of Nursing & Midwifery, King’s
College London, London, United Kingdom.

Received: 5 July 2016 Accepted: 20 September 2017

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Abstract
Background
Methods
Results
Conclusion
Background
Methods
Aim
Study design and setting
Ethics
Sampling and data collection
Data analysis
Rigour
Results
Protecting normality
Education and decision making
Continuity
Empowerment for WCC
Building capacity for WCC
Discussion
Strengths and limitations
Implications for practice and research
Conclusion
Abbreviations
Acknowledgements
Funding
Availability of data and materials
Authors’ contributions
Ethics approval and consent to participate
Consent for publication
Competing interests
Publisher’s Note
Author details
References