Keywords

Introduction

Since time began, women have been supported by other women during childbirth. Midwifery as a profession, however, is a more recent phenomenon. In most high-income countries today, midwives are prepared through tertiary level education and the profession is regulated and often supported by professional associations. Midwifery is unique amongst the healthcare professions because it mostly focuses on physiological processes and a period of transition in the life of a woman and her family. Childbearing and the transition to parenthood is an expression of wellness for many women and families.

Midwives work across the childbearing continuum with women including preconception, pregnancy, labour, birth and the postpartum periods (ICM, 2017). An important part of their role is health promotion whether this involves education in the preconception or antenatal time or optimizing labour and birth outcomes in the intrapartum period by protecting and promoting physiological birth (McNeill et al., 2012). This latter role has become increasingly important against the backdrop of increasing and unnecessary obstetric intervention in normal childbirth , a trend that is contributing to increasing perinatal morbidity and mortality in high-income settings (Villar et al., 2006). In the postnatal time, midwives assist women and families as they transition to parenthood while also having a central role to play in promoting, protecting and supporting breastfeeding, one of the most impactful health-promoting activities in which a woman can engage (Horta & Victora, 2013).

Midwives work with women across the health-ease dis-ease continuum. While the autonomous scope of midwifery practice lies in normal childbirth with well women, midwives also have an important part to play in the care of women with health complexities in close collaboration with medical or other colleagues (ICM, 2017). Midwives can be found wherever, whenever and however a woman grows, gives birth to and nurtures her baby. Whatever the setting or practice context, the unifying feature of midwifery is an approach to practice known as the midwifery model of care.

The “midwifery model of care” (a term coined by sociologist Barbara Katz Rothman in 1979) (Katz Rothman, 1979) describes midwifery as primary health care focusing on the promotion of wellness through empowering women to be confident in their childbearing capacities and to be active agents in their health care (Wagner, 1998). This speaks to a feminist ethic and to an orientation towards wellness. The midwifery approach to childbearing focuses on wellness rather than illness, works with physiology to avoid unnecessary intervention and works closely with women no matter their current state of health, to help them mobilize their own resources to move towards greater health. It is perhaps this health-promoting potential of midwifery that creates such resonance between salutogenesis and midwifery (Downe, 2010).

This approach contrasts sharply with the pathogenic approach to maternity care which is ubiquitous in contemporary healthcare provision. A pathogenic approach focuses on the risk of disease or pathology. In the preconception and antenatal time, it means that much attention is paid to screening for disease or deficiencies and in labour and birth, to monitoring and measurement of labour progress with a keen eye to the detection of deviations from obstetric norms. In the postnatal period, the focus is on maternal recovery from childbirth and monitoring of the baby to ensure it meets expected milestones and norms, for example, weight gain. In research, a pathogenic focus means that negatively framed research outcomes such as measures of morbidity and mortality are used rather than salutogenically focused outcomes such as wellness and physiology (Smith et al., 2014).

While a pathogenic approach has its place, its dominance in modern health care and particularly in the arena of childbearing, which by and large is a healthy undertaking, is problematic. Pathogenic-focused practices, services and research are not creating health in the maternity care context. In many high resource settings, it has led to a phenomenon referred to as “too much, too soon.” This describes the over-medicalization of childbirth and overuse of interventions which, when used injudiciously, cause more harm than good (Miller et al., 2016). It is time for a new approach, and salutogenesis offers much promise.

Can Midwifery Practice Be Salutogenic?

While there is resonance between midwifery practice and salutogenesis , research examining the relationship is in its infancy. Two studies have examined the fit of salutogenesis and midwifery practice: one drawing on interviews with midwives and the other, published studies reporting women’s experiences of midwifery care. A small European study examined the health orientation of 27 midwives in Switzerland, Austria and Germany and found that midwives were oriented towards the protection of physiological processes and that their practice was implicitly underpinned by components of sense of coherence: comprehensibility, manageability and meaningfulness. Comprehensibility was promoted by midwives as they sought to understand the woman and her needs, provided orientation and security within the maternity care system and enabled the woman to control her experience. Meaningfulness was fostered by practices focusing on assisting the woman in meeting the challenges of childbearing and manageability was a dimension in this study that reflected the midwives’ experience, the presence or absence of conflict especially in relation to the paradigms of risk and health orientation (Meier Magistretti et al., 2016).

A systematic review using best-fit framework synthesis applied the concepts comprehensibility, manageability and meaningfulness to 349 quotations from 31 qualitative studies into women’s experiences of midwifery care. This study found salutogenesis to be a good fit for midwifery practice as experienced by childbearing women. In this study, comprehensibility was described as the ways that midwives help women increase predictability and preparation for childbearing. Manageability was described as the ways that midwives enhance and support a woman’s capacity and resources for managing pregnancy, labour, birth and parenting and meaningfulness as the ways that midwives encourage the commitment and engagement of childbearing women with their experience (Mathias, 2019). These studies suggest that there is an alignment between salutogenesis and midwifery practice.

Salutogenesis and Midwifery Research

Despite the alignment between midwifery and salutogenesis, few researchers explicitly draw on salutogenic theory. Two scoping reviews have identified research focusing on sense of coherence (Ferguson et al., 2014) and salutogenic theory (Perez-Botella et al., 2015) in the maternity context. Perez-Botella et al. (2015) conducted a systematic review with the aim of understanding how salutogenesis has been defined and used in maternity care research. They identified eight studies that used salutogenic theory and wide variation in the way the theory was used with most using it in a limited way. Ferguson et al. (2014) described 15 studies that have measured sense of coherence, finding that women with strong sense of coherence had improved emotional health, are more likely to engage in healthy behaviours and seek useful support. These women are also more likely to experience uncomplicated birth, birth at home, and identify normal birth as their preferred mode of birth. Following on from this scoping review, Ferguson et al. (2016) conducted a longitudinal study demonstrating that women with a strong sense of coherence have half the rate of caesarean section compared to women with a weak sense of coherence. In addition, regardless of the mode of birth, women with a strong sense of coherence are more satisfied with their childbirth experience. This finding was the impetus for developing the salutogenic childbirth education program described in the following paragraphs.

Childbirth Education

Childbirth education is viewed by pregnant women and health professionals as an important component of pregnancy care with most health professionals recommending it and most first-time expectant parents using the service (Fabian et al., 2005). A lack of clear aims, content, processes and guidelines makes evaluation difficult (Bergstrom et al., 2009) creating doubt about its value (Gagnon & Sandall, 2007; Davis & Walker, 2011; Murphy, 2008; Ferguson et al., 2013). In their systematic review comparing individual and group childbirth education, Gagnon & Sandall (2007) found that the effects of antenatal education for childbirth or parenthood or both are largely unknown. Ferguson et al.’s (2013) structured review of the childbirth education literature found no evidence of an effect on women’s labour and birth outcomes. Murphy (2008) claims that antenatal education promotes dependency and coercion into compliance with hospital policies and procedures and often deprives women of freedom and choice. Rather than promoting health, childbirth education has been criticized for preparing women and their partners for a medicalized birth (Walker et al., 2009; Ferguson et al., 2013). This reflects the general orientation of contemporary maternity care, underpinned by pathogenesis (Perez-Botella et al., 2015) and risk (Shaw, 2013).

The model of salutogenesis may provide a useful alternative to the biomedical approach as a theory focused on discovering the causes of health rather than the causes of illness (Antonovsky, 1979). Antonovsky suggests that a salutogenic rather than a pathogenic orientation is a more viable paradigm for health promotion, research and practice (Antonovsky, 1996). Salutogenic work moves away from the identification of deficits and problems and moves towards emphasizing a person’s capabilities (Heimburg, 2010). The theory of salutogenesis may provide a useful alternative framework for childbirth education. The study described briefly below aimed to compare outcomes for women attending a conventional childbirth education program with those attending a salutogenic childbirth education program.

Salutary Childbirth Education Program

The Salutary Childbirth Education program , a joint initiative of midwives in academia and clinical practice, replaced an existing childbirth education program which needed renewal. The authors collaboratively worked with the theory of salutogenesis and contemporary literature to design the program. The Salutary Childbirth Education program aimed to build the capacity of women/couples for a positive pregnancy, birth and early parenting experience through focusing on generalized resistance resources and increasing individual sense of coherence by strengthening its key components of comprehensibility, manageability and meaningfulness.

Sense of Coherence

Antonovsky believed that sense of coherence as a whole influenced movement on the health/dis-ease continuum (Antonovsky, 1987). However, when considering ways of operationalizing the theory with the aim to move individuals further towards the health end of the continuum, it was important for us to consider the elements of manageability, comprehensibility and meaningfulness separately.

Manageability

Manageability is the behavioural dimension of sense of coherence and reflects the degree to which individuals feel that they have the resources available to them to meet the demands of a situation (Eriksson & Mittelmark, 2017). The Salutary Childbirth Education program is not content focused and does not attempt to provide women/couples with the resources necessary to meet the demands of childbirth and parenting. The program uses active learning strategies aimed at promoting personal responsibility and independence, assisting women/couples to identify their existing resources for managing pregnancy and childbirth and assisting them to identify and realize potential resources.

Comprehensibility

Comprehensibility is the cognitive component of sense of coherence that relates to the extent to which an individual perceives stimuli as understandable, ordered and predictable (Eriksson & Mittelmark, 2017). It is easy for pregnant women/couples to become overwhelmed with increasing amounts of available information and misinformation relating to childbirth available in the media. The aim of the Salutary Childbirth Education program is to improve participant’s ability to identify good quality information and facilitate the development of knowledge related to pregnancy, birth, parenting and maternity care.

Meaningfulness

Meaningfulness is the motivational aspect of sense of coherence and relates to the emotional meaning attached to aspects of an individual’s life and its challenges (Eriksson & Lindström, 2006). In childbearing, this may be related to the ways in which women/couples engage with their experience. Meanings attached to childbirth and parenting are individual and may be underpinned by different personal values. Some women/couples may experience childbirth as spiritual, while others may enjoy the physical challenge. The Salutary Childbirth Education program aims to assist women/couples to understand their values, motivations, needs and desires relating to pregnancy, birth and parenting.

Resistance Resources

Resistance resources are also important elements of the model of salutogenesis and are key to the development of a strong sense of coherence. These may be intrinsic, extrinsic, generalized or specialized. Generalized resistance resources are those available in a broad range of circumstances, while specialized resistance resources may only be used in certain circumstances (Eriksson & Mittelmark, 2017). We use the term “resistance resources” to refer to all variants. Although Antonovsky (1987) identified that generalized resistance resources were characteristics of a person, group or community, in our Salutary Childbirth Education program, we have a focus on those of the individual. Sense of coherence and resistance resources have a reciprocal relationship where an individual’s resistance resources may contribute to their sense of coherence, and their sense of coherence may contribute to their use of resistance resources (Idan et al., 2017).

The Salutary Childbirth Education program consists of four, two-hour sessions with a focus for each session following the chronology of pregnancy to parenting. The salutogenic curriculum shifts the focus away from complications of pregnancy towards health. A salutogenic orientation is reflected in the four sessions which were carefully named: “growing babies , growing families,” “a labour of love,” “ways of birth” and “healthy families.” Midwives leading each session are facilitators rather than teachers, and those attending are positioned as active participants engaged in exploration and knowledge and resource generation. In all topics, facilitators help focus discussion on ways women and their partners can promote health regardless of where they might be situated on the health/dis-ease continuum. While a non-judgmental attitude is employed, the program unashamedly promotes practices and choices known to positively impact health.

The Study

This study and its findings are presented in full elsewhere (Davis et al., 2019). Therefore, a brief summary is provided here. The study used a longitudinal survey design (before and after) with two questionnaires administered to participants (pregnant women attending education sessions) at two time points to two different groups. The control group (existing standard childbirth education program) was administered one questionnaire in the antenatal period, and one postnatally. Following the development and implementation of the Salutary Childbirth Education program , the intervention group (pregnant women attending the Salutary Childbirth Education program) was administered identical questionnaires antenatally and postnatally. Groups were not run concurrently; after the development and implementation of the Salutary Childbirth Education program, the standard program was discontinued.

The first questionnaire provided information on Sense of Coherence (SOC) scores, personal history, demographics and pregnancy plans. The second questionnaire provided information on SOC scores, labour and birthing outcomes and feedback about the childbirth education program. The study utilized the SOC 13 questionnaire, comprising 13 items measured on a 7-point Likert scale creating possible scores of 13–91. Scores between 13 and 63 corresponded to low and scores between 80 and 91 corresponded to high SOC (Eriksson & Lindström, 2005). Ethical approval was obtained from the relevant Human Research Ethics Committee.

The hypothesis of the study was that there would be a significant difference in the mean score change in SOC between groups from the antenatal to postnatal time. Comparisons were made between groups using students t-test with significance set at 0.05.

Findings

In the standard childbirth education group (control group), 201 women completed questionnaire one and 105, questionnaire two. In the Salutary Childbirth Education group (intervention group), 228 women completed questionnaire one and 115, questionnaire two. There were no statistically significant differences in demographic variables between the two groups. There was a statistically significant difference in the mean SOC score change between groups with women in the intervention group experiencing a greater increase in SOC score from the antenatal to postnatal time than the control group (5.16 increase vs. 1.83 p = 0.032).

Discussion

Scholars and practitioners in midwifery have long since identified the potential salutogenesis holds for midwifery (Downe & McCourt, 2004). To date, few have operationalized the theory in the development of a therapeutic intervention. There is good evidence associating a strong sense of coherence with improved health and health behaviours in childbearing women (Ferguson et al., 2014) including our own longitudinal study (Ferguson et al., 2016) which found that women with a strong sense of coherence experienced half the rate of caesarean section compared to women with a weak sense of coherence. This body of evidence provided a strong basis for the development of the Salutary Childbirth Education program .

One of the few other studies to operationalize salutogenesis is in the context of mental health (Langeland & Vinje, 2017). The authors developed a “talk therapy” intervention program with the aim of increasing the sense of coherence of participants. The similarities of this program and the Salutary Childbirth Education program include the following:

  • The aim to increase participant’s consciousness of and confidence in identifying useful resources that will support well-being

  • Attention to where meaning lies for the participant

  • “Homework” to extend the group work and to position, the individual as an active participant and

  • Acknowledgement that individuals are expert in their own lives and thus professionals are positioned as facilitators rather than experts.

    This program demonstrated effectiveness in improving the sense of coherence of participants (Langeland et al., 2007).

While Antonovsky (1987) believed that sense of coherence was stable over adulthood, researchers have since found that it is more malleable. For example, in large studies conducted in Scandinavia sense of coherence increased with age (Eriksson & Mittelmark, 2017), although studies including long-term follow-up are few. Our longitudinal study into sense of coherence in a pregnant population found that sense of coherence increased and decreased from the antenatal to the postnatal time with levels of birth satisfaction (Ferguson et al., 2016). Childbirth education framed in a perspective of salutogenesis can now be added to the interventions that increase the sense of coherence.

Conclusion

While midwives care for women located at all points on the health-ease dis-ease continuum, they have special expertise in promoting physiological birth and working with women to build their capacity for pregnancy, birth and parenting, whatever their health status. Much of this work is health promotion. The focus on pathology that underpins contemporary maternity care has not served childbearing women well. Pregnancy and childbirth are over-medicalized and are at the point of doing more harm than good. It is time for a new approach. Salutogenesis, with its focus on health rather than pathology, offers a promising way forward. The fit between salutogenesis and midwifery has long been recognized though few have operationalized the framework in the context of midwifery practice. The chapter provides an overview of a project that successfully operationalized the salutogenic framework to produce Salutary Childbirth Education that raised the capacity of women/couples for a positive pregnancy, birth and early parenting experience through focusing on generalized resistance resources and increasing individual sense of coherence by strengthening its key components of comprehensibility, manageability and meaningfulness. Next steps could extend the salutogenic approach beyond childbirth education to maternity services in general.