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versión On-line ISSN 2223-6279
versión impresa ISSN 0379-8577

Curationis vol.36 no.1 Pretoria ene. 2013




Woman-centred care in childbirth: A concept analysis (Part 1)



Maria S. MaputleI; Hiss DonavonII

IDepartment of Advanced Nursing Science, University of Venda, South Africa
IIDepartment of Medical Biosciences, University of the Western Cape, South Africa





'Woman-centred care' in childbirth is a process in which a woman makes choices and is involved in and has control over her care and relationship with her midwife. The aim of this paper is to study the concept of woman-centred care through analysis in the context of childbirth. The attributes, antecedents and consequences of this concept are identified, and a model case, a borderline case and a contrary case constructed to achieve conceptual clarity. A concept analysis was undertaken as described by Walker and Avant (2011), with an extensive exploration of domain-specific literature and evidence from various disciplines.
It was established from the concept analysis that 'woman-centred care' was complex and experienced individualistically. The analysis indicated that mothers' participation is supposed to be based on a more collaborative relationship and partnership. Participation is exhibited by open communication and the mother's involvement in decision-making, consultation and collaboration with the attending midwife, further characterised by mutual respect and the midwife listening to the mother's views. There is also an exchange of complete and unbiased information, recognition and honouring of cultural diversity and making of informed choices. Through an inductive discovery approach and drawing on inferences, attributes were clustered in an attempt to identify the apparent essence of the concept.
From the results of the concept analysis described in this study, the researchers recommend the formulation of criteria that could facilitate implementation and evaluation of woman-centred care and its empirical referents in the context of the Batho Pele principles (Part 2).




A concept can express the same idea, in various sets of words (Tofthagen & Fagerstrom 2010:21). The aim of concept analysis is to clarify meanings of similarity and identify multiple considerations for measuring the concept (Falan 2010:143). Concept clarification is an important step in developing useful and usable knowledge in childbirth. In this article concept analysis was conducted subsequent to research undertaken in the tertiary academic hospital complex of the Capricorn district in Limpopo Province, that determined experiences of childbirth of mothers (Maputle & Nolte 2008) and their attending midwives (Maputle & Hiss 2010).

A qualitative exploratory, descriptive, contextual and inductive research approach was followed. The sample consisted of 24 mothers and 12 attending midwives. Different data collection methods were used. Data obtained from unstructured in-depth interviews were analysed according to the protocol by Tesch (1990, cited in Creswell 2003:155). Data analysis from participant observations using a semi-structured approach and visual analogue scale was performed quantitatively using frequency distribution.

After a description of the experiences of mothers and attending midwives of childbirth, a synthesis of the results from the empirical data, supported by a literature control, revealed the core category as 'woman-centred care'. The research was conducted in four phases: phase 1 - empirical, phase 2 - concept analyses (which this paper addresses), phase 3 - model development, and phase 4 -model validation.

Problem statement

A synthesis of results from empirical data on the experiences of mothers and attending midwives of childbirth, as supported by a literature control, revealed the core category as 'woman-centred care'. The concept 'woman-centred care' has frequently been used in literature; however, there is no consensus about its meaning and its use in childbirth. This article used Walker and Avant's (2005; 2011) method of concept analysis as a framework to analyse woman-centred care.


The situation in hospitals that provide childbirth care is such that prescribed routines are adhered to frequently, as laid down in the policies and procedures which are strategically placed in the ward. Midwives generally regard it as their responsibility to ensure that the rules are adhered to. Pearson, Vaughan and Fitzgerald (1998:34) indicate that the end results of such an approach are standardised routines for mother care during childbirth. They further point out that mothers are often expected to comply with a predictable pattern and follow the routine laid down by the regulations. Adherence to such standardised routines may have substantial merit, but when followed without skilled assessment pose a significant risk of depersonalising mothers and discouraging their full participation and involvement during midwifery care.

Standardised routines can also be viewed as part of the biomedical model, which has a dominant effect on health care as it serves mainly the relevance of midwives to their public roles during childbirth. The biomedical model is characterised by a concentration of information and decision-making in the hands of doctors and midwives, and to a lesser extent in those of women. The emphasis of the model is more on high technology, that leads to the loss of basic human care. Women are labelled according to their diagnoses, rather than being recognised as patients with needs that call for appropriate attention and responsiveness. Nevertheless, Pearson et al. (1998:37) affirm that the biomedical model is well developed and undoubtedly gives indispensible direction to midwifery practice.

It is not surprising that pressure from society coupled with increased understanding of human nature through the Patients' Rights Charter and Batho Pele principles have highlighted the restrictive nature of the biomedical model, the alternative approach being the provision of 'woman-centred care'. The Batho Pele principles seek to introduce and orient midwives towards a customer-focused approach that will improve systems, procedures, attitudes and behaviour within childbirth units (Department of Public Service and Administration 1997). The White Paper aptly indicated that this did not necessarily mean introducing more rules and centralised processes, or micro-managing service delivery activities. Rather, it involved creating a framework for delivery of public services which treated citizens more like customers and enabled them to hold public servants to account for the services they rendered.

The White Paper on the Transforming of Service Delivery (Department of Public Service and Administration 1997)- through the eight Batho Pele principles (consultation, service standard, courtesy, access, information, openness and transparency, redress, and value for money) aims to overhaul the entire standard of the public service and encourage effective service delivery. Services should be based on a customer-orientated framework. These principles were integrated within the context of the concept 'woman-centred care' (Table 1). The Department of Public Service and Administration (1997) indicates that the importance of public service delivery lies in the need to build confidence and trust between the provider (midwife) and the user (mother) through openness and transparency. Sandall (1995:201) and Midmer (1992:216) support the notion of customer-oriented service delivery, arguing that the philosophy and focus should shift from technologisation to personalisation, and to building a paradigm of 'woman-centred practice' based on equal partnership between mothers and attending midwives.

Aim of the study

The aim of the study was to conduct concept analysis of woman-centred childbirth care in order to clarify meanings of similarity and identify multiple considerations for measuring the concept. Hence the research question addressed in this article is: What is the meaning of woman-centred care in childbirth?


Research design and methods

Research design

An inductive-discovery approach that focused on identification of relevant aspects of the concept was used, as the researchers sought to identify what is common in the use of the concept (Rodgers 1993:79). A concept analysis was conducted in order to obtain the operational definition and to define attributes, antecedents and consequences of the concept 'woman-centred care'. In addition, a model case, a borderline case and a contrary case were constructed to achieve conceptual clarity (Malusky 2005:28; Sun & Knobf 2008:334).

Concept analysis is used to examine and describe a concept and its application. The objective is to understand what the concept is about (Walker & Avant 1988, cited in Walker & Avant 2005:63, 84). The concept should be clear and distinct, unambiguously defined and well differentiated from other concepts, and should be applicable to the world and appropriate to the context (Chabeli & Muller 2004:38). Concept analysis is applied for the refinement and definition of concepts originating from nursing practice, nursing research and nursing theory (Falan 2010:146). This would facilitate- differentiation between similar and dissimilar concepts. Walker and Avant (2005:63-84) assert that concept analysis and development are fundamental processes required by nurse researchers who are attempting to measure the metaphysical phenomena of nursing (midwifery) practice. They further state that by definition, concept analysis is a process of operationalising a phenomenon so that it can be used for theory development and/or research measurement. They implied, thus, that a scientifically developed concept is the essential first step in any research process. Concepts are viewed as the building blocks with which theory can be constructed, and their analysis is considered essential if the concepts are to be actively and correctly operationalised (Eustace & Ilagan 2010:2095; Mikkelsen & Frederiksen 2011:1154). Walker and Avant (2011; 2005:63-84) were leading pioneers in adapting theoretical work related to concepts for the discipline of nursing. They based their process on the work of Wilson (1963, cited in Walker & Avant 1995), truncating the 13 steps into eight basic elements, which included selection of an appropriate concept through development of model cases, and to identification of 'empirical referents'.

Methods: Concept analysis

The framework suggested by Walker and Avant (2005:63-84) was used for the analysis described in this research. The method included:

  • selection of the concept
  • specification of the aims of analysis
  • identification of uses, characteristics or connotations of the concept
  • determination and definition of attributes
  • development of model cases which exemplify the analysis
  • identification of antecedents and consequences
  • definition of empirical referents.

A study 'Experiences of childbirth by mothers at the tertiary hospital in Limpopo Province' was conducted (Maputle & Nolte 2008), and experiences of the mothers during childbirth revealed the major concept 'woman-centred care'. 'Woman-centred care' emerged as a core concept because it was found to be the central idea or event, and all the other categories and attributes were contingent upon it. The concept was also relevant to childbirth care within the framework of the Batho Pele principles directed at a customer-focused approach. An extensive literature search of computerised databases and manual searches of online journals were also undertaken to ensure that characteristics associated with the concept of woman-centred care were included in the search terms. Literature-based analysis included specific disciplines, for example nursing, medicine, humanities and nursing management.

Aims of analysis

In the process of analysis the characteristics of the concept and surrogate terms were identified and the related concepts, antecedents and consequences were documented. The researcher used all the steps outlined in Walker and Avant (2005:63-84). An extensive literature search was conducted to achieve the aims of analysis. The main aim of the analysis was to offer a medium for identifying the shared meaning of imaginative concepts. It further explored the use of the concept 'woman-centred care' within the context of childbirth units. The critical attributes of 'woman-centred care' as both process and product had to be identified, and differences between 'woman-centred care' and 'midwife-centred care' distinguished. The analysis determined the meaning of the concept 'woman-centred care' and its usefulness, applicability and effectiveness as a key concept in childbirth. Moreover, concept analysis was used to define a term for subsequent research or to examine how a concept was used within the current literature or in actual clinical practice (Chinn & Kramer 1995:81).

Identification of uses, characteristics or connotations of the concept

To accomplish identification of the uses, characteristics or connotations of the concept, a dictionary and the impressions of colleagues and available literature on the subject were used. Unsworth (2000) affirms that dictionary definitions are authentic and therefore useful because they convey accepted ways in which words are used. This paradigm can be useful in defining the scope of any subsequent analysis of the literature. The woman is part of the family. However, the concept of 'woman-centred care' is frequently not well-defined in dictionaries. The concept analysis of Hutchfield (1999:91) was adopted to define the use of family-centred care (woman-centred care). This definition suggested that family-centred care (woman-centred care) was a holistic approach, with professionals and family working collaboratively towards a common outcome. The opportunity was thus given to the family members to care for their relative (during childbirth). The collaboration allowed independence and the possibility of co-opting the family into the plan of care. Family-centred care was firmly entrenched in respect for and cooperation with the family.

According to this view, the nurse was an equal partner and a facilitator of care. The empowerment of women during childbirth is possible, but may need to be conceptualised differently from family-centred care. It was thus proposed that woman-centred care shifted the emphasis to the mother as the key figure in childbirth, and granted her the mandate to personalise her childbirth to suit both her needs and those of her family. In childbirth, for example, the concept 'woman-centred care' was used in relation to mutual participation and interdependent collaboration. According to Hutchfield (1999:90), the literature gathered focus on identifying the essential nature or 'essence' of the concept in the form of attributes. The attributes are not dictionary definitions, but represent the 'real definition of the concept'.

'Woman-centred care' is a core concept that refers to involving the woman in treatment decisions, increasing communication between the midwife and woman towards an understanding of what to expect from treatment plans,- recovery and aftercare (Bechell, Myers & Smith 2000:402). Johnson, et al. (2003:30) refer to 'woman-centred care' as a process in which a woman makes choices, and is involved in and has control over her care and relationship with her attending midwife. Likewise, 'woman-centred care' encourages the mother to articulate her ideas and views. As partners, the mother and the midwife take the mother's emotional and social environment into account and require mutual participation (Anderson 2002:80).

'Woman-centred care', according to Rush (1997), cited in Hutchfield (1999:94), refers to a complex, multidimensional, dynamic process of providing safe, skilled and individualised care. It responds to the physical, emotional and psychosocial needs of the mother. However, 'woman-centred care' as outlined within the context of the Batho Pele principles in the White Paper on Transforming Public Service Delivery (Department of Public Service and Administration 1997), is customer-oriented care, in the following manner: a midwife consults the mother, encourages her involvement and supports her choices about the services offered. A mother is allowed to practice preferences (courtesy), with equal access to personal control and decision-making (access). Moreover, a mother is given full and accurate information about childbirth and the midwifery care to which she is entitled. Unsworth (2000:65) refers to 'woman-centred care' as the sum of activities that includes emotional involvement, responsible participation and a sharing of practical and technical knowledge of health care.

Connotations of 'woman-centred care' that emerged from the literature

In this study 'woman-centred care' was seen as a philosophy of care that brought about mutual participation and the involvement of both the mother and the attending midwife. However, Nethercott (1993), cited in Hutchfield (1999:90), identifies the differences between a mother's involvement and participation. Involvement is