Exploring birth experience of mother based on comfort theory

11 Objective: To analyse the phenomenon of "giving birth" on the basis of the lived 12 experiences of women and midwives. 13 Method: The qualitative study was conducted in the delivery room of a mother-14 friendly hospital in western Turkey from March 1 to December 30, 2019, and 15 comprised primiparous women aged 18-35 years having a spontaneous vaginal birth, 16 and midwives who delivered the babies. Data was collected through indepth 17 interviews that were audio-recorded. Additionally, women’s written birth stories and 18 researcher’s observation regarding the participants were used. Data was subjected to 19 content analysis using NVIVO 12 Pro software. 20 Results: Of the 28 subjects 15(53.6%) were lay women with mean age 24.2±3.87 21 years (range: 18-30 years), and 13(46.4%) were midwives with mean age 42.61±4.50 22 years (range: 37-50 years). The most referred conceptual themes in Kolcaba’s Theory 23 of Comfort were “enhanced comfort”, “mother-friendly hospital policy”, and 24 “midwives’ comforting interventions.” Under the theme of "Increasing Comfort", 25 women cared about psychological and environmental comfort. Women had the most 26 psychospiritual comfort and environmental comfort as well as physical and


Introduction
Pregnancy and childbirth are natural and normal processes. 1They are also the most beautiful and valuable life experiences for women and their families. 1However, today, with the effect of developing technology, women are not independent in managing the birth process, as childbirth is medicalised, and unnecessary interventions are made. 24] .In Turkey, the first such studies were initiated in 2011, 5 and mother-friendly hospital practice was launched as a pilot practice in 3 hospitals on April 17, 2015.The efforts to disseminate this practice have been continuing throughout the country. 51][12] However, to our knowledge, no study adapting this theory to childbirth and midwifery care has been conducted.The evaluation of P r o v i s i o n a l l y A c c e p t e d f o r P u b l i c a t i o n women's labour comfort remains an important research topic.However, comfort is a difficult concept to evaluate objectively. 12current study was planned to analyse the phenomenon of "giving birth" on the basis of the lived experiences of women and midwives in a mother-friendly hospital, using 10 comfort determinants of the Kolcaba's Theory of Comfort; "women's health care needs", "midwives' comforting interventions", "ıntervening variables", "enhanced comfort", "health-seeking behaviours", "easy birth", "perception of difficult birth", "institutional integrity", "mother-friendly hospital policy", and "best practices".[10][11][12]

Subjects and Methods
The qualitative study was conducted in the delivery room of a mother-friendly hospital in western Turkey from March 1 to December 30, 2019.Approval was obtained from the institutional ethics review committee, and permission was taken from the provincial directorate of health.The sample was raised using purposive sampling method.During the sample selection, diversity was ensured by including participants with different characteristics, such as education, job, age, etc., to obtain varied type of data.Those included were primiparous women aged 18-35 years having a spontaneous vaginal birth (SVB), and were able to speak Turkish.Those outside the age range, multiparous, those who had a caesarean section (CS), were not willing to participate, and those who could not speak Turkish were included.The sample also enrolled midwives who delivered the babies, had been working in the delivery room for at least 6 months, were willing to participate, and could speak Turkish.Those who did not meet the criteria were excluded.
After taking written informed consent from all the participants, data was collected through indepth interviews.All data collection tools were used in Turkish in a way the participants could understand.
The women's information form consisted of questions identifying sociodemographic and marital characteristics, income status, residence, family type and educational

P r o v i s i o n a l l y
A c c e p t e d f o r P u b l i c a t i o n background (Table 1).The midwives' information form consisted of questions identifying sociodemographic characteristics, job duration and satisfaction with the unit (Table 2).4] The interview forms were evaluated by five specialists; 1 obstetrics and gynaecology specialist, 1 public health nurse, and 3 midwives.Their suggestions were used to revise the forms after the experts suggested increasing the number of probes for physical, psychological, environmental and sociocultural comfort in the forms.Before collecting data, a pilot study was conducted with 3 women to ensure the form's credibility and trustworthiness.Some relevant changes were made in the light of the pilot study.When we look at the manufacturing sources of the data; Primary data production consisted of individual interview records obtained from in-depth interviews and women's birth memories.Secondary data sources are delivery room observation data.
Other than the semi-structured interviews women's written birth stories, and researchers' observation notes.
Before starting the study, the researchers made observations in the delivery room for 20 working days as part of an official assignment.The data collection process started with the observation notes.The observation notes were prepared for secondary data analysis.
The participating women were interviewed at home after making an appointment in the hospital room at their convenience after delivery.They were given A4-sized paper and a pen to write down their birth memories, and asked to write down their feelings and experiences freely.After 2-3 days, the women submitted their written birth stories on the scheduled appointment day.
The midwives were interviewed at the hospital or in their homes, depending on the appointment time.During the interview, some women were alone at home, some were accompanied by their mothers or mother-in-law or spouses or neighbours.No one refused or dropped out because the women felt ready and had made an appointment at their own convenience.However, 2 women whose time could not be planned

P r o v i s i o n a l l y
A c c e p t e d f o r P u b l i c a t i o n appropriately, could not participate in the study.There was no repeated interview.
Two interviews were held with women and midwives.Participating midwives were interviewed at the hospital, an appointment was made, and they were interviewed at their homes at the appointment time.In the second interview with an appointment, indepth interviews with women and midwives were completed.
The introductory characteristics form was filled out during indepth individual interviews.Then, face-to-face indepth interviews were conducted under the guidance of the semi-structured interview form.To facilitate the indepth interview, a quiet, calm environment was chosen, the participants' privacy was ensured, and it was made sure that the participants shared their feelings and experiences sincerely and comfortably about giving birth/delivering a baby.More information about the participants, their feelings and thoughts about giving birth/delivering a baby were obtained by asking alternative questions and probes.The interviews were recorded using a digital voice recorder (Olympus Digital Voice Recorder VN-541 PC; 1570H-Vietnam), which enabled the researcher to obtain complete and accurate participant responses.The researchers kept a journal at each interview and took observation notes.
The interviews continued until data saturation occurred.Data saturation was also used as the determinant of the sample size which is a valid tool in qualitative research. . 15r the interviews were completed, the researchers listened to the audio recordings within 24 hours, and the raw data was transferred to the computer and made ready for analysis in a Microsoft Word document.There were 10 components of Comfort Theory [12][13][14] used in the study.Theme tags were created with a deductive approach.
However, in coding, an inductive approach was used to conduct content analysis to bring together and interpret similar data within the framework of a certain concept.
Two coders coded the responses separately and a single code list was created according to coding consistency.Ten themes were created by analysing the gathered data.
For participant confirmation, feedback was ensured by interviewing 5 participants (2 midwives and 3 women) regarding the findings.

P r o v i s i o n a l l y A c c e p t e d f o r P u b l i c a t i o n
Data was analysed using the Creswell 4 steps technique.This process is carried out by pre-reading, coding qualitative data, obtaining themes, organising, interpreting, and reporting the data. 16NVIVO 12 Pro software was used for data analysis.When presenting data, frequencies (f), and code numbers with the abbreviation of midwife (M), woman (W), story (S), master's degree (M.D.), high school degree (H.S.D.), university degree (U.D.) were used.The ages of the interviewees are also given when presenting the data.The transcripts of the interviews were given back to the midwives to validate or correct the comments.However, it was not given to women because they could not reschedule an appointment at home.For authenticity data, compatibility of observation and birth memories data with interviewers' transcripts was checked.At the end of the data analysis, the accuracy of the data was checked by the experts.
The credibility of the study was ensured by the fact that 1 researcher (obstetric nurse) collected data, while the others analysedit. 17Open coding was done.
0] To ensure intercoder reliability, 10% of the text sections was randomly selected from the encoded text after the interview (1 of a woman and 1 of a midwife) and the code list was sent to another researcher who was an expert not part of the current study.The accuracy rate of the codes was 98.06%.

P r o v i s i o n a l l y
A c c e p t e d f o r P u b l i c a t i o n All the 13(100%) midwives were working in the delivery room of the mother-friendly hospital.In terms of level of education, 1(7.7%) midwife had completed high school, 4(23.1$) had associate's degrees, 8(61.5%) had bachelor's degrees and 1(7.7%) had completed master's degree.All the 13(100%) midwives had been working as midwives for >10 years, and were associated with the delivery room for >6 months.
The most referred conceptual themes among the 10 identified were "enhanced comfort", "mother-friendly hospital policy", and "midwives' comforting interventions" (Figure ).
Under the theme of enhanced comfort, subthemes "psychospiritual comfort," "environmental comfort," "physical comfort," and "sociocultural comfort" were described.According to 1 woman, "I had a natural birth.I went into the water and did Pilates, and my labour was very easy.We can say that we had a lot of fun with the midwives during the birth; our midwives were very caring and friendly at the beginning.They turned on the music and sang songs.The reason why I preferred the state hospital is that I attended pregnancy school for 4 weeks.And I have overcome my fears.And I met the midwives and learned the exercises that make birth easier, and, thanks to our friendly midwives, I had an easy and beautiful birth."(Memoir W3, 22, H.S.D.) One midwife explained the sociocultural comfort of pregnant women was increased.
"We also respect the patients.We allow them to do it; birth takes place when the Virgin Mary's grass is fully opened.Yes, they bring Zamzam water, we see that, and then they eat something with a prayer, you know, they eat dates-like fruit."(Interview M3, 50, Ü.D.) Under the main theme of mother-friendly hospital policy, subthemes "satisfaction with policy practices", "policy practice of allowing a birth companion", "problems in practices", "evidence-based practice", "suggestions to improve the policy", "dissatisfaction", "hospital preference (service recipient)", "policy practice of single

P r o v i s i o n a l l y A c c e p t e d f o r P u b l i c a t i o n
room", "professional midwifery", "pregnancy school", "midwife-pregnant meeting" and "supportive care opportunity" were described.
A woman wrote in her birth story that she was satisfied with the policy practices."I had a very comfortable birth, thanks to our midwives.Everything was perfect in our hospital.I would give birth in this hospital again if I could do it again for their cleanliness, care and attention.There was nothing I was dissatisfied with; everything was perfect.They also let my husband in, and I am glad they let my mother in." (Birth story W11, 22, H.S.D.) One midwife described her satisfaction with the policy."I mean, we are a motherfriendly hospital, we already have single rooms, our workload was more before, but now our workload is less in single rooms, and then the fact that the pregnant women are satisfied with the services we provide to them allows us to get our professional satisfaction from the profession we do conscientiously.In general, I am satisfied with all of the mother-friendly hospital practices."(InterviewM9, 38, M.D.) Under the theme of midwives' comforting interventions, subthemes "routine practices", "mother-friendly practices", "paying attention to privacy initiative", "providing information initiative", "mother-friendly practice-service recipient", "establishing trust initiative", and "midwives' allowing a birth companion" were described.
One midwife explained the mother-friendly practices and how they involved the father in the birth."Of course, as soon as the baby is born and they have skin-to-skin contact, we put the baby on her lap before cutting the umbilical cord.After the beating stops, we cut the baby's cord, and we make the father cut the umbilical cord.We make the three of them hold their hands together (two seconds of silence), then we try to breastfeed the baby after the process is over."(Interview M10, 39, U.D.) One woman described she was empowered by midwives at birth and her experience of an easy birth."There were 2-3 midwives.

Discussion
Based on women's experiences in the antenatal, intrapartum and postnatal periods in the mother-friendly hospital, and midwives' experiences of delivering a baby, 10 main themes emerged in line with Kolcaba's Theory of Comfort.When paired with the components of the conceptual framework of the theory, some changes emerged, and the number of themes dropped from 11 to 10.Since the theory evolved from the physiological process of birth and midwifery care, focussing on health-seeking behaviour, the theme of "peaceful death" was excluded.The two themes that changed completely were "internal behaviour" and "external behaviour."In their place, two themes were labelled as "easy birth" and "perception of difficult birth".
A mother-friendly hospital policy addresses the needs of each woman.2] As a result of the mother-friendly hospital policy, in addition to providing environmental comforts, such as single room, room temperature, lighting, reducing distracting noises, oral nutrition, massage, movement, position, music and non-pharmacological methods, such as water birth, have been observed to increase physical comfort.Women expressed feeling peaceful during labour and described the birth as being easy.
[29] P r o v i s i o n a l l y A c c e p t e d f o r P u b l i c a t i o n practices, such as using the Virgin Mary's grass, increases sociocultural comfort.
During the interviews, the midwives expressed their admiration for women's cultural practices and emphasised the assistance they provide.1][32][33][34] Similarly, in the current study, women and midwives reported that physical, psychological, environmental and sociocultural comfort facilitated labour and delivery in the mother-friendly hospital.The participants were generally satisfied with the changed service delivery and enhanced comfort as a result of the policy.
Based on the participants' experiences, the third main theme was the "midwives' comforting interventions".The midwives provided constant care and support, resulting in a seamless transition for women from the antenatal to postnatal period.This was achieved despite the intensity and exhaustion of the intrapartum period.
In this study, women expressed their satisfaction with the conditions in the delivery room, the care and support provided by the midwives, and the social support provided by having their husbands or other family members present.The women spoke with satisfaction about skin-to-skin contact managed by the midwives, their husbands cutting the umbilical cord, and the midwives' support for breastfeeding.The findings of the study were consistent with literature [35][36][37][38] It is the main responsibility of midwives to prepare the delivery room, manage the delivery, and care for the mother and newborn safely. 39In addition to routine practices, midwives observing mother-friendly practices pay attention to privacy, passing on information, building trust, and recruitment of companions 28,40,41,[42][43][44][45][46] Mother-friendly practices of midwives increase comfort.The resulting model showed a relationship among enhanced comfort, health-seeking behaviour and easy birth.
Mother-friendly hospitals can be said to support a holistic care approach.With In the current study, the midwives stated that there was institutional integrity in the mother-friendly hospital; all staff adopted mother-friendly hospital criteria, worked as a team, and the hospital management supported the delivery room team.In addition, they emphasised that they received training in line with the changing service delivery, and developed themselves professionally.In line with these findings, the motherfriendly hospital policy can be said to contribute to the professionalism of midwives.
The current study had some limitations.The findings of the study emerged from the thoughts, perceptions and experiences of the participants who gave birth and had their babies delivered in a mother-friendly hospital in Turkey.The data obtained from pregnant women was based on their recollections of their birth experiences.For this reason, those in the delivery room may have missed some details during their meetings with the researcher during the appointment.The researcher asked them to write down their birth memories to address this limitation.In addition, there were interruptions in conversations with the baby after birth and disruptions in the appointment plan.

Conclusion
Kolcaba's Theory of Comfort was found to be an appropriate and functioning theory for childbirth and midwifery care, and that comfort should be provided in the psychospiritual, environmental, physical and sociocultural contexts, which are the stages of comfort for women's empowerment and naturalisation of birth.

P r o v i s i o
n a l l y A c c e p t e d f o r P u b l i c a t i o n enhanced comfort, it is possible to reduce CS deliveries made at the mother's request without a medical necessity, and to improve the health of the mother and the baby.