An Integrative Literature Review On Midwives Perceptions On The Facilitators And Barriers Of Physiological Birth

R E V I E W
An integrative literature review on midwives' perceptions on
the facilitators and barriers of physiological birth
Cassandra Y.W. Wong BSc (Nurs) (Honours), RN, Staff Nurse1 |
Hong‐Gu He PhD, MD, Associate Professor2 |
Shefaly Shorey PhD, MSc. BSc, Assistant Professor2 |
Serena S.L. Koh PhD, Associate Professor2
1
National University Hospital, National
University Heath System, Singapore
2
Alice Lee Centre for Nursing Studies, Yong
Loo Lin School of Medicine, National
University of Singapore, Singapore
Correspondence
Shefaly Shorey, Alice Lee Centre for Nursing
Studies, Yong Loo Lin School of Medicine,
National University of Singapore, Level 2,
Clinical Research Centre, Block MD11, 10
Medical Drive, Singapore 117597.
Email: nurssh@nus.edu.sg
Abstract
Aim: To present a synthesis and summary of midwives' perceptions on the facilitators and bar-
riers of physiological birth.
Background: Medicalisation of birth has transformed and dictated how birthing should take
place since the 20th
century. Midwives' perceptions on their role within this medicalised environ-
ment have not been well documented.
Design: An integrative literature review.
Data sources and review methods: Primary research articles published in English from the period
of 2004 to 2015 were included in this review. The Joanna Briggs Institute's critical appraisal
forms were used to appraise the quality of the articles. Data were identified from CINAHL,
PubMed, PsycINFO, ScienceDirect, and Scopus.
Results: Eighteen articles were reviewed. Lack of knowledge due to inadequate training,
existing obstetrician‐led practices, and midwives' negative perceptions of physiological birth
were identified as barriers in the literature. Facilitators like shared decision‐making, women's
preferences, teamwork, institutional support, and midwives' positive perceptions of physiolog-
ical birth promoted physiological birth. Most of the studies were conducted in Western
countries.
Conclusion: Midwives face barriers and facilitators when promoting physiological birth dur-
ing their clinical practise. Future studies exploring midwives' perceptions of physiological birth
are needed, especially in Asia where cultural and organizational factors may differ from Western
countries.
KEYWORDS
barriers, facilitators, literature review, midwives, normal birth, physiological birth
SUMMARY STATEMENT
What is already known about the topic?
• The advancement in technology and an increasing domination of obste-
trician‐led childbirths have resulted in the medicalisation of childbirth.
• Midwives' perceptions on their role in the medicalised birthing envi-
ronment are not well documented.
What this paper adds:
• Midwives identify several barriers and facilitators in promoting
physiological birth.
Received: 23 February 2017 Revised: 31 August 2017 Accepted: 13 September 2017
DOI: 10.1111/ijn.12602
Int J Nurs Pract. 2017;e12602.
https://doi.org/10.1111/ijn.12602
© 2017 John Wiley & Sons Australia, Ltd
wileyonlinelibrary.com/journal/ijn 1 of 15

• Most of the available literature on midwives' perceptions on physi-
ological birth are from the West.
The implications of this paper:
• Cultural‐specific and country‐specific future studies are needed to
explore the perspectives of both midwives and labouring women
surrounding birthing issues.
• Policies surrounding maternity services need to be improved so that
unnecessary medical interventions can be prevented and positive
birth outcomes can be promoted.
1 | INTRODUCTION
Labour and childbirth are normal physiological processes (Canadian
Association of Midwives, January 2010). However, the advancement
in technology as well as an increasing domination of obstetrician‐led
childbirths has resulted in the medicalisation of childbirth (Malacrida
& Boulton, 2014). Although the use of technology has generally
lowered maternal and foetal mortality rates during labour and delivery
(Wall et al., 2010), women are subjected to more unnecessary
interventions (Scamell & Alaszewski, 2012), and, ironically, subsequent
risks are brought to both mother and foetus (Buckley, 2015).
Nonetheless, it seems that the natural, or physiological, way of birth
is becoming more attractive to mothers in developed countries (Fox
et al., 2013). Alvarez (2014) attributed this trend to women becoming
more educated and, hence, more equipped to make informed
decisions.
A previous literature review (Romano & Lothian, 2008) highlighted
that normal physiological birth can be promoted by following 6 evi-
dence‐based care practices: (1) abstaining from a gratuitous initiation
of labour via medical methods, (2) permitting the labouring woman
the liberty for movement, (3) offering constant labour support, (4)
abstaining from the usual interventions and restrictions such as intra-
venous therapy and continuous electronic foetal monitoring, (5) pro-
moting delivery in non‐supine positions, and (6) maintaining contact
between the mother and the baby after birth with no limitations to
breastfeeding. In this review, physiological birth is defined as undergo-
ing labour and delivery without medical interventions such as analgesia
and episiotomy, including the 6 evidence‐based care practices of phys-
iological birth (Romano & Lothian, 2008).
The midwifery profession advocates for women to be offered the
perspective that childbirth can be healthy and that not all deliveries
require active medical intervention. Midwives are there for most of a
woman's intrapartum journey in the delivery suite (Borders, Wendland,
Haozous, Leeman, & Rogers, 2013) and play a significant role in
influencing the decision‐making process of women in labour (Jefford,
Fahy, & Sundin, 2010). A recent Cochrane review revealed that women
whose pregnancy and birth were attended by midwives had an
increased likelihood of achieving a spontaneous vaginal delivery and
were less likely to receive an epidural, episiotomy, or an instrumental
delivery (Sandall, Soltani, Gates, & Shennan, 2016). The benefits of
receiving continuous midwifery‐led care are also highlighted in a study
conducted in Singapore, which showed a positive correlation between
1‐to‐1 midwifery care and associated maternal and neonatal benefits
such as skin‐to‐skin and early breastfeeding initiation (Fox et al.,
2013). These findings provide justification to the role of midwives in
helping women to achieve normal physiological births. Seeing the
importance of midwives for women in labour, this literature review
aims to present a synthesis and summary of midwives' perceptions
on the facilitators and barriers of normal physiological birth. The bar-
riers of physiological birth will first be illustrated, followed by the facil-
itators. Finally, gaps in the literature and implications for future studies
will be highlighted.
2 | REVIEW METHODS
2.1 | Aim
This review aimed to provide a synthesis of evidence pertaining to
midwives' perceptions on the facilitators and barriers of physiological
birth.
2.2 | Design
The integrative review approach, involving both quantitative and qual-
itative studies, was adopted.
2.3 | Search methods and search outcomes
Databases of CINAHL, PubMed, PsycINFO, ScienceDirect, and Scopus
were searched extensively to identify relevant articles for the literature
review. The inclusion criteria were primary research articles that:
1. were published in the English language between years 2004 and
2015, and
2. explored midwives' perceptions on the facilitators and barriers of
normal physiological birth.
The exclusion criteria were articles that:
1. were unpublished, conference proceedings, opinion papers, sys-
tematic reviews, meta‐analyses, meta‐syntheses, or secondary
data analyses,
2. included participants who did not receive formal midwifery train-
ing, such as perinatal nurses working in labour and delivery,
3. explored the views of other participants such as obstetrician and
patients, and
4. explored midwives' perceptions on women with disabilities, high‐
risk pregnancies, and home birthing.
The keywords used in various combinations were “midwife”,
“perception”, “view”, “meaning”, “experience”, “physiological birth”,
“natural birth”, “labouring positions”, “facilitators”, and “barriers”.
Appropriate articles were also derived from the reference list of the
identified articles. Figure 1 illustrates the outcomes of the search
strategies.
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2.4 | Data abstraction, quality appraisal, and synthesis
A data abstraction form was developed to retrieve information from
each article. Before being included in the present literature review,
the methodological quality of each study was first assessed using the
Joanna Briggs Institute's (JBI's) Critical Appraisal Forms (The Joanna
Briggs Institute, 2014). The authors agreed upon meeting a minimum
threshold of 60% of the criteria for an article to be included in the
literature review. The corresponding author and the first author
appraised the articles individually and discussed the findings together.
When in doubt, a third person was invited to appraise the articles. Two
thousand three hundred and ninety‐one articles were retrieved after
limiting the initial search results for publication type, year of
publication, and language. After screening their titles and abstracts,
the resulting 35 full‐text articles were assessed using the JBI's Critical
Appraisal Forms. Eighteen studies, of which 16 were qualitative and 2
were quantitative, achieved at least 60% of the appraisal criteria. Due
to the nature of the studies included, data pooling was not possible,
and the findings were synthesized as a narrative summary.
3 | RESULTS
The following section summarizes the common barriers and facilitators
of physiological birth, as identified by the reviewed articles. The
barriers of physiological birth include lack of knowledge due to inade-
quate training, existing obstetrician‐led practices, and midwives' nega-
tive perceptions of physiological birth. Shared decision‐making,
women's preferences, teamwork, institutional support, and midwives'
positive perceptions of physiological birth were the facilitators that
promoted physiological birth. A summary table of the reviewed articles
is presented in Table 1.
3.1 | Barriers to physiological birth
3.1.1 | Lack of knowledge due to inadequate training
A lack of knowledge was identified as a barrier to the provision of
physiological birth. Midwives were so used to their usual medical
procedures during birth that they often felt unprepared when caring
for women who opt for physiological birth (Hadjigeorgiou & Coxon,
2014). If exposed to more non‐medicalised childbirths during their
training, student midwives would feel more prepared and confident
in assisting with physiological births (Hadjigeorgiou & Coxon, 2014).
This finding was supported by Davis (2010), whose midwives in his
study highlighted the significance of the need for midwifery educators
to incorporate more experiential learning for their students to enhance
their confidence in normalcy.
FIGURE 1 Flow diagram depicting the outcomes of the search strategies
WONG ET AL. 3 of 15

TABLE 1 Description of the included studies (n = 18)
Qualitative studies
Author (year) Aim of study
Design and data
collection methods Setting Participants Findings
Joanna Briggs Institute
Critical Appraisal outcome
(percentage of checklist met)
Aune, I., Amundsen,
H. H., Skaget Aas,
L. C. (2014)
To gain an
understanding
on midwives'
experiences
of providing a
continuous
supportive
presence in
the delivery room
during childbirth,
and to learn
about the factors
that may affect this
continuous support.
Qualitative
descriptive
design
Semi‐structured
interviews
A large maternity
unit in Norway
Purposive sampling
of 10 midwives
(with 1–30 years
of experience) from
2 different
maternity wards
Used the term “natural birth”.
Themes:
1. Relational competence
2. Midwife's ideology
3. Culture and philosophy of
the maternity unit
85.5%
Carolan‐Olah, M.,
Kruger, G., &
Garvey‐Graham, A.
(2014)
To explore midwives'
experiences and
views of the factors
that facilitate or
impede normal birth
Phenomenology
with van Manen
approach
Interviews
A public hospital
in Australia
Purposive sampling
of 22 midwives
(1 male; 1 year
to >10 years
of experience)
Used the term “normal birth”:
Spontaneous in onset, low‐risk
at the start of labour, and
remaining so throughout
labour and delivery.
Barriers:
• Time pressures on the amount
of time a woman can spend in
the labour unit
• A risk adverse culture where
there was an emphasis on
proactively managing
pregnancy complications
and potential problems
• Midwives' views on women's
expectations
a) Lack of antenatal education
Facilitators:
• A supportive environment
a) Support for the midwife
b) Support for the woman
• Midwifery attributes
a) Experience and confidence
b) A desire to promote
normal birth
c) Additional effort
d) Strategies to promote
normal birth
80%
Dahlen, H. G., &
Caplice, S. (2014)
To determine the
top fears of
midwives in
Australia and
Qualitative
descriptive
design midwives
wrote down on
17 workshops held
in Australia and
New Zealand
Convenience
sampling of
Australian and
New Zealand
Death of a baby (n = 177), missing
something that causes harm
(n = 176), obstetric emergencies
(n = 114), maternal death (n = 83),
90%
(Continues)
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TABLE 1 (Continued)
Qualitative studies
Design and data
New Zealand
when caring for
childbearing
women
a piece of paper
their greatest fear.
These fears were
then collected
in a box, mixed
up, collated,
and reported back
anonymously to
the group.
over the period
of 2009–2011
midwives and
student midwives
who attended
the workshop
being watched (n = 68), being the
cause of a negative birth experience
(n = 52), dealing with the unknown
(n = 36), and losing passion and
confidence around normal birth
(n = 32). Student
midwives were more
concerned about knowing
what to do while
homebirth midwives were
mostly concerned with
being blamed if something
went wrong.
Davis, J. A. (2010) To describe and define the
concept of normalcy as
the critical characteristic
of the midwifery model
of care in a specified
category of midwives
Phenomenological‐
hermeneutic
methodology
One‐to‐one
interviews
Nominated nurses
from the American
College of
Nurse‐Midwives
Purpose sampling of
13 (12 CNMs
and 1 CM) out of
20 nominated
midwives who
were working in
hospitals,
free‐standing
birth centres, and
at home
Midwives experience normalcy
in childbirth care as:
1) A wide individualized
continuum of variations
2) interactive with a woman's
unique nature, composed of
her physiologic capacities and
her specific life circumstances
3) sensitive and responsive to
the contextual environment
100%
De Jonge, A.,
Teunissen, D. A.,
van Diem, M. T.,
Scheepers, P. L., &
Lagro‐Janssen, A. L.
(2008)
To explore the views of
midwives on women's
positions during the
second stage of labour
Qualitative descriptive
design
Focus group
interviews
The Netherlands Purposive sampling of
31 independent
primary care
midwives, divided
into 6 focus
groups with a
mixture of midwives
from either
rural, semi‐urban,
or urban areas in
each group
Informed consent:
Midwives implicitly or explicitly
ask a woman's consent for
what they prefer.
Informed choice:
A woman's preference is the starting
point, but midwives will suggest
other options if these are in the
woman's interest.
Obstetric factors and working
conditions hinder women's
preferences.
88.8%
Earl, D., & Hunter, M.
(2006)
To gain a deeper
understanding of
how midwives work
within these busy
settings in relation
to their challenges
with respect to
“keeping birth normal”
Phenomenology
with
van Manen
approach
Interviews
2 tertiary hospitals
in New Zealand
Purposive and
snowball sampling
was used to recruit
8 midwives (with a
range of experience
from 2 to 30 years)
Outcome of a spontaneous
vaginal birth.
Stepping back or stepping in:
Doing something minor to
prevent major interventions
(eg, balancing technology
use and intervention with
patience and non‐
intervention)
100%
(Continues)
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TABLE 1 (Continued)
Qualitative studies
Design and data
Everly, M. C. (2012) To explore the
factors
that affect
the labour
management
decisions of
midwives
in hospitals and
free‐standing
birth centres
Grounded theory
Unstructured
tape‐recorded
interviews
Recruitment of
midwives at
the American
College of
Nurse‐Midwives
Annual
Meeting and
Exposition
in 2009 and 2010,
held in the United
States of America
Purposive sampling of
10 midwives who
had a previous
experience
in providing labour
and birth
Management in
both hospitals
and free‐standing
birth centres
4 themes:
1. Trust birth
2. The woman
3. The team
4. The environment
90%
Hadjigeorgiou, E., &
Coxon, K. (2014)
To provide an
exploration
of the perceptions
of midwives as
client advocates
for normal
childbirth
Qualitative design
Participant
observation
and semi‐
structured
interviews
3 maternity
departments
in Cyprus
public hospitals
Purposive sampling
of 20 midwives,
10 took part in
semi‐structured
interviews, 10
consented to
being observed
through participant
observation
Used the term
“normal birth”, but
did not define
meaning.
5 main interconnected
themes emerged:
• Barriers
1. Lack of professional
recognition
2. Deficiencies in basic
or continuing education
• Structural factors
3. Physician dominance
4. Medicalisation of
childbirth
5. Lack of institutional
support
95%
Hammond, A.,
Foureur, M., &
Homer, C. S. (2014)
To explore the impacts
of the physical
and aesthetic
designs of hospital
birth rooms on
midwives
Ethnography
Video filming,
video‐reflexive
interviews, and
field notes
2 public tertiary
level teaching
hospitals in
Australia
Convenience
sampling of 7
registered
midwives and
1 student midwife
Midwives were strongly
affected by the design
of the birth room.
4 major themes:
1. Finding a space among
congestion and clutter
2. Trying to work
underwater
3. Creating ambience in a
clinical space
4. Being equipped for
flexible practice
Aesthetic features, room layout,
and the design of equipment
and fixtures all impacted the
midwives and their practice
in both birth centre and
labour ward settings.
90%
(Continues)
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TABLE 1 (Continued)
Qualitative studies
Design and data
Hunter, B. (2004) To explore how a
range of midwives
experience and
manage emotions
during their work
A qualitative
study using an
ethnographic
design
Focus groups,
observations,
and semi‐
structured
interviews
United Kingdom 3 phases:
Phase 1: Self‐selected
convenience sample
of 27 student
midwivesin the first
and final years of
18‐month (post‐
nursing qualification)
and 3‐year long
(directentry) programmes
phase 2: Opportunistic
sample of 11 qualified
midwivesrepresenting
a range of clinical
locations and clinical
grades phase 3:
Purposivesample of
29 midwives working
within 1 National Health
Service Trust
representing a range
of clinicallocations,
length of clinical experience,
and clinical grades
Used the term “natural
approach to maternity
care”:
Not only by their
expressed confidence in
physiological processes but
also by their focus
on the psychosocial
aspects of care.
With institution ideology
• Hospital midwifery was
dominated by meeting
service needs via a
universalistic and
medicalised approach
to care.
• Midwives experienced
work as emotionally difficult
and requiring regulation of
emotion, i.e. “emotion work”.
With woman ideology
• Community‐based midwifery
was more able to support an
individualized natural model
of childbirth.
• Midwives experienced
their work as emotionally
rewarding.
90%
Keating, A., &
Fleming, V. E. (2009)
experiences of
facilitating normal
birth in an
obstetric‐led
unit
A feminist
approach
Semi‐structured
interviews
3 maternity
units in an
Irish hospital
Purposive sampling of
10 midwives
Used the term “normal birth”,
where the woman's innate
ability to birth physiologically
is respected and promoted.
4 main themes:
1. Hierarchical thinking
2. Power and prestige
3. A logic of domination
4. Either/or thinking
7 subthemes:
• Senior/junior midwives
• You have to be strong
• You are influenced, put
under pressure
• Midwives are influenced
by the doctors
• Interventionist versus
non‐interventionist birth
environment
100%
(Continues)
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TABLE 1 (Continued)
Qualitative studies
Design and data
• Active management
of labour versus
physiological birth
• Objective scientific
knowledge versus
women's ways of knowing
Page, M., &
Mander, R. (2014)
perceptions of
intrapartum
uncertainty
when caring
for women in
low risk labour
Grounded theory
Unstructured 1‐
to‐1 interviews
and focus
groups
Scotland Purposive and
theoretical
sampling of 19
midwives from
obstetric‐led labour
wards, along‐side
maternity
units, stand‐alone
community
maternity
units, and
community and
independent
practice
3 categories emerged:
1. Intrapartum uncertainty
2. The normality boundary
3. Threshold pressures
88%
Russell, K. E. (2007) To describe labour
ward midwives'
experiences of
supporting
normalbirth
in obstetric
led units
Grounded theory
Semi‐structured
interviews
2 obstetric units
in the United
Kingdom
Purposive sampling
followed by
theoretical
sampling
of 6 midwives
(3 from each
obstetric unit)
a vaginal birth without
instruments, induction,
epidural, or general
anaesthetic.
1. Labour ward hierarchy
2. Labour ward practices
3. Normal birth knowledge
and skills
100%
Salomonsson, B.,
Wijma, K., &
Alehagen, S. (2010)
To describe
midwives'
experiences
with and
perceptions
of women with
fear of childbirth
Qualitative study with
a phenomenological
approach
Focus group
4 types of hospital
in Sweden
Purposive sampling
of 21 experienced
midwives divided
into 4 focus
groups
4 description categories
emerged:
1. Appearance of fear of
childbirth
2. Origins of fear of
childbirth
3. Consequences of
fear of childbirth
4. Fear of childbirth
and midwifery care
65%
Stone, N. I. (2012) To investigate and
describe the
approach of
midwives
practicing
birth assistance
Grounded theory
Semi‐structured
interviews and
participant
observation
A free‐standing
birth centre in
Germany
Convenience sampling
of 5 midwives who
were interviewed
and 9 births were
observed
An event situated within a
woman's life—with her body,
its physiological processes,
and needs in the moment
as the focus.
90%
(Continues)
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TABLE 1 (Continued)
Qualitative studies
Design and data
at a free‐standing
birth centre
Normality is abandoned
as soon as medication
is administered.
Findings from interview:
• Negotiating normality at
the birth centre
• Use of interventions
(homeopathic remedies/
“gentle” interventions)
only during emergency
Findings from participant
observation:
1. Making physiological
birth possible: Objective
and subjective data as
guideposts, allowing a
holistic approach to birth
2. Babies form medical
objective to human being
3. Use of medical discursive
at birth centre
Thorgen, A., &
Crang‐Svalenius, E.
(2009)
To investigate midwives'
views and
experiences of the
different aspects
of working with
specificareas of
interest in:
• The midwives' personal
views of midwifery at
birth centres
• Work‐life balance
• Organization of care,
eg, whether
continuity of
care was being
practised
• Booking criteria and
medical back‐up
Descriptive qualitative
design
Personal interviews
3 birth centres in
the United
Kingdom
Snowball sampling of
9 midwives (a few years
to 30 years or more
of experience)
Used the terms “normal birth”
and “natural birth”:
Practising and promoting
normal midwifery
care enabled the experience
of natural births.
1 main category:
• Autonomy of practice
5 subcategories:
1. Midwifery aspects
2. Professional development
3. Flexibility and work demand
4. Independence
5. Interprofessional
relationships
100%
Quantitative studies
Osborne, K., &
Hanson, L. (2012)
1. To describe the
practices used by
certified nurse‐midwives/
certified midwives
in response to maternal
bearing‐down efforts
Quantitative descriptive
study questionnaires
were mailed to
participants
United States
of America
Random selection of
705 certified
nurse‐midwives
/certified midwives
from the list of active
members in the
Women without epidural:
82.4% would initiate bearing‐
down efforts, 67% reported not
providing direction but
supporting spontaneous
bearing‐down efforts,
85.7%
(Continues)
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TABLE 1 (Continued)
Qualitative studies
Design and data
when caring for women
in second‐stage labour
2. To identify factors
associated with the use
of supportive approaches
to second‐stage labour care
American College
of Nurse‐Midwives
using a computer‐
generated
random numbers table
and 79.6% would provide
more directions as the
foetal head emerged
and the final stretching of
the perineum was
taking place.
Women with epidural:
Most reported using more
directive practices, 77.1%
would provide more direction
as the foetal head emerged and
the final stretching of the
perineum was taking place.
90.6% would provide
more direction during
bearing‐down efforts when
foetal safety is compromised,
73.3% would provide more
direction upon request, and
74.6% would provide more
direction when women
appeared fatigued.
Styles, M.,
Cheyne, H.,
O'Carroll, R.,
Greig, F.,
Dagge‐bell, F., &
Niven, C. (2011)
intrapartum referral
decisions in relation
to their dispositional
attitudes towards risk
Quantitative
Web‐based correlation
study with
between‐group
comparisons using
questionnaires and
vignettes
4 health board
areas in Scotland
Convenience sampling
of 102 midwives
providing labour
care in both
consultant‐led units
and community
maternity units
Midwives made a wide range
of referral decisions.
No association
between referral
scores and measures
of risk, personality,
or years of experience.
Statistically significant difference
between the 4 health board areas:
Midwives from 1 area made referrals
at a significantly earlier stage.
83.3%
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3.1.2 | Existing obstetrician‐led practices
Medical practices were commonly identified as barriers. Within the
hospital environment where the medical model takes precedence,
obstetricians are often the main decision‐maker, followed by
experienced midwives, newly joined midwives, and labouring women
(Keating & Fleming, 2009; Russell, 2007). The autonomy of a midwife
is dependent on the obstetrician (Hadjigeorgiou & Coxon, 2014;
Keating & Fleming, 2009; Russell, 2007), and challenging medical
interventions require confidence on the midwives' part (Hadjigeorgiou
& Coxon, 2014). It is crucial for obstetricians and midwives to attain
mutual respect (Aune, Amundsen, & Aas, 2014) as having a positive
working environment will make the achievement of a physiological
birth within a hospital possible (Carolan‐Olah, Kruger, & Garvey‐
Graham, 2015).
An emphasis on obstetrician‐led births also led to lack of support
from the institution and other health care providers, for the midwives
to participate in practices that promote physiological birth. It was
noted that promoting such practices in obstetric‐led units caused Irish
midwives to feel less confident and infuriated as they were unable to
use their midwifery expertise (Keating & Fleming, 2009). It also placed
younger midwives in a position that invited criticism from their senior
colleagues. These findings mirrored that of Carolan‐Olah et al. (2015),
where Australian midwives also felt that working against the dominant
medical model provoked derision. In the United Kingdom, as part of a
grounded theory study, midwives who supported physiological birth
were labelled by their colleagues as “mad” while doctors called them
“bolshie”, a negative term associated with professional conflict (Russell,
2007). Although the clinical experiences of midwives in terms of the
number of years differed among these studies, their accounts were
generally biased towards pro‐physiological birth. It could be that the
authors in all 3 studies chose to report only positive findings or those
who opposed physiological birth did not participate in the studies
and were thus not presented.
Insufficient support from the institution was demonstrated
through a lack of staff who support physiological birth, with midwives
mentioning that institutional policies often focused on the efficiency of
managing more patients and revenue associated with high patient vol-
ume (Hunter, 2004). This was supported by another study in which the
organization was concerned with making money, providing homoge-
neous care, and diminishing risks (Hunter, 2004). As a result, all birthing
women were subjected to high‐risk protocols and placed on electronic
foetal monitoring even if these procedures were not necessary
(Carolan‐Olah et al., 2015). Sometimes, the midwives did not agree
with managing labour actively but hospital protocols hindered them
from objecting (Hadjigeorgiou & Coxon, 2014). Hammond, Foureur,
and Homer (2014) investigated how the architectural and aesthetic
designs of hospital birth rooms influenced midwives and discovered
that space constraints and poor facilities impacted midwifery practice
greatly. Despite its small sample size, data triangulation and data anal-
ysis by all authors enhanced the trustworthiness of the findings (Field
& Morse, 1985; Hammond et al., 2014).
Inadequate support from managers was also raised in 2 studies
(Hadjigeorgiou & Coxon, 2014; Hunter, 2004). The lack of managerial
support was reflected from poor staffing during each shift. The high
amount of workload and paperwork resulted in midwives spending
most of their time performing non‐supportive care (Hunter, 2004),
thus compromising the quality of care provided (Hadjigeorgiou &
Coxon, 2014). It appeared that hospital midwifery stressed on the
accomplishment of tasks and building relationships with colleagues
rather than with labouring women (Hunter, 2004).
3.1.3 | Negative perceptions of physiological birth
Supporting physiological birth can be time‐consuming and psychologi-
cally exhausting. Midwives who worked within a nurse‐managed unit
in a hospital reported that caring for a woman who chose physiological
birth would entail a midwife/nurse‐patient ratio of 1‐to‐1 because the
woman would require continuous labour support (Aune et al., 2014).
Occasionally, the woman's inability to cope with the situation can chal-
lenge this process, which can be emotionally draining for the midwife/
nurse (Aune et al., 2014). Using interviews, such negative aspects also
emerged from midwives working in free‐standing birth centres
(Thorgen & Crang‐Svalenius, 2009) and obstetric‐led environments
(Carolan‐Olah et al., 2015; Earl & Hunter, 2006), proposing that
supporting physiological birth is time‐consuming and emotionally
draining, regardless of the level of autonomy possessed by the mid-
wives/nurses.
Although Thorgen and Crang‐Svalenius' (2009) study had a rela-
tively smaller sample size, there was heterogeneity, and the findings
were congruent with other studies. All participants in the studies had
several years of clinical experience and were females, except for 1
study that also interviewed a male midwife (Carolan‐Olah et al.,
2015). Only 1 study reported balanced views for physiological birth
(Aune et al., 2014).
Midwives admitted that they would sometimes advise pregnant
women to use epidural when their workload was high. This was due
to insufficient time for providing labour support (Aune et al., 2014),
and women on epidural were generally more comfortable (Carlton,
Callister, Christiaens, & Walker, 2009). Surprisingly, these midwives'
behaviours were independent from physicians' influences, possibly as
a form of coping with the demanding workload related to organizational
needs (Aune et al., 2014; Carlton et al., 2009). In a study conducted by
Hunter (2004), participants working in the hospital environment felt
disconcerted when they provided fragmented care to labouring women
due to the need to complete all their assigned tasks before the shift
ended. They felt frustrated for not being able to fully fulfil the role of
a midwife. Similar findings were also reflected in Carolan‐Olah et al.'s
(2015) study where the immense workload and hectic pace of the unit
within the hospital were causal factors of Australian midwives' stress
levels. Additionally, midwives' fears related to their work can contribute
to pressure and exhaustion in the workplace eventually (Dahlen &
Caplice, 2014). The implications of this finding, however, were limited
as the fears of midwives were not explored in detail.
Another aspect that could be emotionally taxing on midwifes/
nurses is when a woman enters the delivery suite with a birth plan.
In a Swedish study, 1 midwife felt that birth plans negatively affected
the midwife‐woman relationship as it evoked pressure and a sense of
insufficiency in the midwife. It is unknown whether the other midwives
within the focus group had similar feelings (Salomonsson, Wijma, &
Alehagen, 2010).
WONG ET AL. 11 of 15

3.1.4 | Sense of uncertainty
Midwives who had been working for decades in the hospital environ-
ment lost confidence in supporting physiological birth and the domi-
nance of the medical model prohibited them from developing the
necessary skills for physiological birth (Keating & Fleming, 2009). This
lack of confidence can possibly contribute to their sense of uncertainty
because the norm practice has been managing labours actively and
intervening early (Page & Mander, 2014). Page and Mander (2014)
examined midwives' perceptions towards intrapartum uncertainty in
low‐risk labour to better understand the variations in which midwives
decide to make referrals. The participants reported that practice and
experience were inversely proportionate to their sense of uncertainty.
Midwives in the study by Stone (2012) contested the notion of nor-
mality, in which normal births were abnormal occurrences in the hospi-
tal. Interestingly, medical justifications were viewed as a valuable tool
in helping midwives define the boundaries of normality, alleviating
women's uncertainties, and averting risks. In a phenomenological study
with the aim of understanding the term “normalcy” by midwives when
caring for women during labour and childbirth, midwives supported
various meanings of normalcy during clinical practice to develop a
woman's belief and ability in her own delivery (Davis, 2010). Similar
to Page and Mander (2014), the informants believed that a higher
threshold for normalcy is accompanied by experience.
3.2 | Facilitators of physiological birth
3.2.1 | Shared decision‐making
A significant facilitator of physiological birth is the shared decision‐
making process between a pregnant woman and her midwife. A previ-
ous research (de Jonge, Teunissen, van Diem, Scheepers, & Lagro‐
Janssen, 2008) investigated how midwives perceive birthing positions
adopted by women during the second stage of labour using focus
group interviews. It was found that midwives utilized the shared deci-
sion‐making process by either asking which position a woman prefers
(informed consent) or offering information and suggestions to help
her make her choice (informed choice). Midwives in Osborne and
Hanson's (2012) study also reported that they would use supportive
or directive approaches. However, these practices were used to
describe maternal bearing‐down efforts and were dependent on when
and why a woman had epidural, including signs of foetal distress and
maternal request. Nevertheless, the midwives highlighted that
women's preferences on different birthing positions should be
discussed during their pregnancy. Of equal importance is to prepare
women for unforeseeable negative feelings that might develop during
labour or circumstances that would require the adoption of other posi-
tions (de Jonge et al., 2008).
3.2.2 | Women's preferences
Women's culture, values, and own beliefs that childbirth is a natural
process is considered a facilitator for midwives to promote physiolog-
ical birth. Specifically, culture and women's preferences can influence
the types of positions utilized during birthing (de Jonge et al., 2008).
Therefore, midwives felt that decision‐making around childbirth should
consider women's wishes and choices (Everly, 2012).
3.2.3 | Teamwork
Teamwork was frequently cited as a facilitator of physiological birth in
the literature (Carolan‐Olah et al., 2015). Respect for different mem-
bers within the delivery team contributes to an affirmative work envi-
ronment, which is highly valued. Similar findings were reported by
Everly (2012), where great teamwork experienced within free‐standing
birth centres positively affected midwives' decisions on labour man-
agement. Receiving support from colleagues and other health care pro-
fessionals enabled midwives to provide better labour support to
birthing women (Carolan‐Olah et al., 2015). Additionally, junior mid-
wives could build on their midwifery skills and confidence within a
constructive environment while being supported psychologically by
their team. This reduces emotional stress and promotes job satisfac-
tion (Hunter, 2004).
3.2.4 | Institutional support
While inadequate support from the institution is a barrier to physiolog-
ical birth, institutional support is a facilitator. Institutional support is
concerned with adequate staffing, well‐equipped facilities, and the
amount of autonomy midwives/nurses possess. In birthing centres,
midwives possess more autonomy and are thus able to engage in more
midwifery practices when compared with their counterparts who work
within a hospital setting (Dahlen & Caplice, 2014; Thorgen & Crang‐
Svalenius, 2009). Additionally, having sufficient staff permitted the
provision of 1‐to‐1 labour support to women in birthing centres
(Thorgen & Crang‐Svalenius, 2009).
3.2.5 | Positive perceptions of physiological birth
Notwithstanding all the challenges experienced in midwifery, the out-
come of labour is a rewarding experience when women achieve physio-
logical births. Midwives mentioned that assisting women in their birthing
process was satisfying. However, Hunter (2004) contested that the expe-
rience was only rewarding when midwives worked “with the women's”
ideology of care, whereby the physiological model of childbirth was sup-
ported (p. 268). For midwives who worked within the hospital, the ideol-
ogy was “with the institution”, where the medicalised model of childbirth
was provided and their experiences were less rewarding (Hunter, 2004,
p.267). Marquis and Huston (2011) explained that the more involved
an individual is with his/her work, the higher their job satisfaction.
Thorgen and Crang‐Svalenius (2009) examined midwives' views and
experiences of working in birth centres and found that despite the
demanding workload, the midwives experienced a sense of accomplish-
ment and fulfilment when they were able to exercise autonomy and uti-
lize their midwifery skills. Similarly, midwives strongly felt that they play
pivotal roles in determining a fulfilling birth experience for their patients.
This, in turn, translated into an affirmative recognition of their role and
positive feedback, which made them feel were worth the investment.
Previous research findings showed that Thorgen and Crang‐Svalenius
(2009) have echoed that of Aune et al. (2014), where midwives who built
a wonderful relationship with the birthing woman experienced a sense of
sadness when their shift ended. Interestingly, Page and Mander (2014)
revealed that even when an uncertainty exists within the intrapartum
period, midwives spoke of “excitement” and “anticipation” (p. 31)
during their course of work.
12 of 15 WONG ET AL.

4 | DISCUSSION
Although the barriers to physiological birth experienced by midwives
were relatively well explored in both qualitative and quantitative stud-
ies of this literature review, the majority of the studies were conducted
in Western countries (23 out of 24). Moreover, the perceptions of mid-
wives who worked within obstetric‐led environments were inconsis-
tent. For instance, the midwives in Carolan‐Olah et al.'s (2015) study
reported both positive and negative reviews on the collaboration
between obstetricians and midwives. Previous studies (Keating &
Fleming, 2009; Russell, 2007) had reported that promoting physiolog-
ical births within environments where obstetricians are the dominant
figure is difficult. There could be a possibility that childbirth has
evolved over the years, whereby emphasis is now placed on interpro-
fessional collaboration instead of obstetricians dominating midwives.
However, some obstetricians might still prefer to make their own
decisions instead of engaging in collaborative practice with midwives.
Nonetheless, these studies lack the perceptions of midwives in the
non‐Western context. Hence, the findings from this literature review
have limited transferability (Polit & Beck, 2004). Future studies can
explore successful models of midwifery so that policies governing mid-
wifery work can be implemented or changed. This will prevent high
attrition rates of midwifery in the industry, which can in turn promote
positive birth outcomes in women.
Among 3 studies that discussed having a sense of uncertainty as
a barrier to physiological birth, both Stone (2012) and Page and
Mander (2014) used the grounded theory approach to capture the
experiences of midwives while Davis (2010) adopted the phenome-
nological‐hermeneutic methodology. The first 2 studies used
methods triangulation, while the third study employed data triangula-
tion to enhance its trustworthiness. Stone (2012) conducted unstruc-
tured interviews and focus groups, while Page and Mander (2014)
used semi‐structured interviews with participant observation. Both
Davis (2010) and Page and Mander (2014) recruited midwives from
various practice sites, but Stone (2012) sampled midwives from only
1 birth centre, which limits its generalisability (Polit & Beck, 2004).
While it is widely known that obstetricians can serve as barriers to
physiological birth, inadequate training resulting in a lack of knowledge
is another significant barrier. For example, Carolan‐Olah et al. (2015)
reported that midwives who had been working in a hospital environ-
ment for a substantial amount of time had lost confidence in supporting
physiological birth as these practices were not the norm. Conversely,
midwives who were well trained had the confidence to support women
in physiological births (Mirzakhani & Shorab, 2015). This lends evidence
that the ability to promote physiological birth is correlated with having
sufficient education, training, and experience. As childbirth is a normal
physiological process rather than a pathological one, training for mid-
wives should revolve around managing birth with minimal medical
interventions. Future interventional studies can look into the effective-
ness of training to improve the confidence level of both student mid-
wives and midwives who have been working in a hospital.
In this review, there was only 1 study (Aune et al., 2014) that
reflected the opinions of midwives who supported the use of medical
interventions. This could be because the midwives felt that their contin-
uous presence during labour is the biggest contributor of a positive birth
experience despite the intricate birthing process. Moreover, technologies
were viewed as tools in the birthing process rather than substitutes for
midwives' presence. More research in this area is warranted to provide
a balanced view of midwives' perceptions towards these practices as
most studies in this review demonstrated the voices of midwives who
supported physiological birth. This is so that any misconception of normal
midwifery practices can be addressed. In addition, perceptions of the
birth plans made by health care professionals have not been examined
in detail. There were inconclusive findings on midwives' negative experi-
ences with birth plans (Salomonsson et al., 2010). In today's society
where the internet is widely available and women are becoming more
educated, it is of interest to study health care professionals', especially
midwives', perceptions on birth plans because they spend a substantial
amount of time with birthing women.
Out of the 21 qualitative studies that were reviewed, only 1 study
(Hammond et al., 2014) examined the physical environment of hospital
birth rooms. Most childbirths occur within the hospital, and different
hospitals have different designs. Thus, it will be noteworthy to explore
the perceptions of midwives within each unique setting in promoting
physiological birth.
Of the studies that recognized shared decision‐making as a facili-
tator of physiological birth, different methodologies of both qualitative
(de Jonge et al., 2008) and quantitative research designs (Osborne &
Hanson, 2012) were used. Although the findings by de Jonge et al.
(2008) could be biased as none of the midwife participants were
against non‐supine positions, a balanced view on the preferences for
supine and other positions were presented. As for Osborne and
Hanson's (2012) study, questionnaires were only mailed to active
members of the American College of Nurse‐Midwives, which is non‐
representative of the non‐active members.
In a grounded theory study by Everly (2012) that discussed team-
work as a facilitator of physiological birth, member checking was per-
formed, which helped to enhance the credibility of the findings. A
sample size of 6 to 10 informants is acceptable (Creswell, 1998). How-
ever, voluntary participation without any means of compensation
might suggest that the results could be skewed towards 1 direction
as it is possible that only those who were supportive of midwifery care
would participate.
4.1 | Limitations of this review
This review has a few limitations. Firstly, the reviewed articles were
first eliminated based on their title and abstract; hence, some
important points within the text of the excluded articles might have
been missed. Secondly, only primary research papers published in
English and between 2004 and 2015 from specific databases were
reviewed, which might have limited the findings presented. Future
reviews considering data presented in grey literature may be more
conclusive.
4.2 | Implications for nursing and health policy
Midwives play a crucial role in advocating and preserving physiological
birth, including the utilization of different positions. During childbirth,
midwives should, to their best ability, provide women and their

partners with necessary support or guidance. Where possible, they
need to educate women and address any misconceptions that women
have surrounding childbirth. Although the differences in culture and
lay advices sometimes prevented midwives from promoting physiolog-
ical birth, it is crucial to consider women's preferences while
preventing any occurrences of potential risks.
As childbirth concerns both obstetricians and midwives, the latter
group needs to know when to step in to advocate for labouring women
in bringing about the best outcome for her and her child. However, the
strong dominance of obstetricians sometimes poses a barrier to mid-
wives from acting so. Policy makers and organizational policies need
to recognize the benefits of midwifery‐led care in order to promote a
recognition of midwives to the general public, as well as allow mid-
wives more autonomy.
It is also important for future studies to explore labouring women's
perceptions surrounding birthing issues within one's unique context as
women in different countries and cultures have different expectations
of childbirth. In this way, maternity services provided within each set-
ting can be better aligned to labouring women's unique needs. This
will, in turn, bring about positive birth experiences for them and their
partners, along with improved foetal outcomes.
5 | CONCLUSION
This review examined midwives' perceptions on the facilitators and
barriers of physiological birth. Labouring women can either have posi-
tive or negative experiences depending on the amount of support they
receive from midwives during their labour and the degree of decision‐
making during the birthing process. The influence of midwives on the
birthing experience of a woman is thus significant. With childbirth
becoming more medicalised and obstetricians being the dominant fig-
ure, policies surrounding maternity services need to be improved so
that unnecessary medical interventions can be prevented and positive
birth outcomes can be promoted.
ACKNOWLEDGEMENT
The authors would like to thank the National University Health
System, Medical Publications Support Unit, for assistance in the
language editing of this manuscript.
AUTHORS STATEMENT
All listed authors meet the authorship criteria and that all authors are in
agreement with the content of the manuscript.
ORCID
Shefaly Shorey http://orcid.org/0000-0001-5583-2814
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How to cite this article: Wong CYW, He H‐G, Shorey S, Koh
SSL. An integrative literature review on midwives' perceptions
on the facilitators and barriers of physiological birth. Int J Nurs
Pract. 2017;e12602. https://doi.org/10.1111/ijn.12602

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