Skilled Attendance Is Not Enough: What Women Said About Being Cared For

In the summer of 2013, I spent three months at a public hospital in San Francisco de Marcoris in the Dominican Republic observing how babies were born and listening to women describe the experience of being born to.

This is a research essay about a gap — the gap between what providers think they are doing during labor and birth and what the women experiencing labor and birth understand they are receiving.

The research was part of a larger community-based participatory research project led by Jennifer Foster, my mentor at Emory. The question was simple but important: what is the quality of maternity care in this hospital, according to the women who receive it?

The Setting

The hospital in San Francisco de Marcoris is a public hospital. It is where most of the women in the surrounding communities deliver their babies. The hospital is not well-resourced. The staff is limited. The infrastructure is constrained. The women who deliver there are often poor, often without options, often giving birth to babies in circumstances that are medically risky.

We stayed at Rosa's house. Rosa was a nurse who had gotten her Master's degree — extraordinary for a nurse in the Dominican Republic at that time, a woman who had pushed against structural limits and succeeded in pursuing education most nurses in her country did not have access to.

Jennifer Foster had established relationships with the hospital and with the staff over years of research. The hospital had agreed to participate in the study. The staff understood that we were there to understand what the experience of birth was like for the women delivering in that hospital.

We were not there to fix anything. We were not there to criticize. We were there to listen and to observe.

What We Observed

Observation is a skill. It is not just looking. It is looking systematically, paying attention to what is happening and what is not happening, noticing patterns and ruptures in patterns, seeing what is visible and also noticing what is absent.

We observed labor and birth. We watched how providers moved in the hospital room. We watched how they communicated (or did not) with the women. We watched how they explained what they were doing. We watched what happened when complications arose.

We observed the routine of the hospital — how women were admitted, how labor was managed, how births were conducted, how the postpartum period was handled.

We observed the informal knowledge that the hospital staff held — the experience that nurses and midwives had accumulated through years of practice, the judgment they used to recognize when something was wrong, the decisions they made moment by moment about what to do next.

We also observed what the providers did not seem to see. Women in labor in pain, communicating their pain, and providers interpreting that pain as normal labor rather than as data about the individual woman's experience. Women asking questions, and providers answering with technical information rather than with explanation of what they were doing. Women expressing fear, and providers moving forward with procedures without acknowledging the fear.

What the Women Told Us

After births, we interviewed the women. We asked them about their experience. We asked what they understood about what was happening during their labor and delivery. We asked what they would want providers to do differently.

The women described two different experiences simultaneously.

The first experience: they understood that the providers were trying to help them deliver safely. They understood that the hospital and the staff were there to help them have a healthy baby. They had come to the hospital because they wanted their baby to be born safely. They trusted the system, in a general way, to accomplish that goal.

The second experience: they often did not understand what was happening to their body. They often did not know why providers were doing specific interventions. They experienced pain and fear and did not have explanation for why those things were happening. They received technical care without explanation or comfort. They gave birth, and they were grateful to have delivered a healthy baby, but the experience of being cared for during birth was often an experience of not understanding what was being done to them and why.

The gap was not small. The gap was between medical care (which was happening) and the experience of being cared for (which was often absent).

A woman in labor does not need only medical expertise. She needs to understand what is happening to her body. She needs to have her pain and fear acknowledged. She needs to have someone present with her in her vulnerability. She needs explanation, not just intervention.

The providers at the hospital had the expertise. They had the skill to recognize complications and manage them. They had the judgment to make decisions about what needed to happen next. They had the experience to know what normal labor looked like and what looked like risk.

But the experience of care — the relational aspect of birth work, the presence, the explanation, the acknowledgment of fear — that was often missing.

What We Learned

The data from that summer became a 2017 publication: "The Process of Intrapartum Care Among Skilled Birth Attendants in the Dominican Republic and Maternal Perceptions of Care During Labor and Birth: A Case Report."

What the research showed was that skilled attendance at birth is important and necessary. The women in the study recognized that. They understood that the providers had prevented complications, had managed risk, had made decisions that kept them and their babies safe.

But skilled attendance alone is not comprehensive maternity care. Comprehensive maternity care includes explaining what is happening. It includes acknowledging the woman's experience. It includes presence and compassion alongside technical expertise.

The providers at the hospital were not unkind. They were not cruel. They were constrained — constrained by time, by resources, by the sheer volume of women arriving in labor. The system did not provide them the space or the time or the support to offer relational care alongside technical care.

The women understood this too. They did not blame the providers. They understood the constraints. But they also understood what they had not received. They understood the gap between technical care and caring care.

What This Means

A woman giving birth is not a medical problem requiring a medical solution. A woman giving birth is a person in a profound state of vulnerability, undergoing a medical event that is also a life event.

The skilled birth attendant needs to have medical expertise. That is necessary.

But the skilled birth attendant also needs to have the skill to be present with a woman in labor. To explain what is happening. To acknowledge fear and pain. To treat the birth as an event that matters not just medically but existentially.

The hospital in San Francisco de Marcoris has providers who have the medical expertise. What they need is support — time, space, training, resources — to offer care that is comprehensive.

That summer in 2013, we observed the gap. We listened to the women describe it. We documented it. The research confirmed what the women already knew: that technical expertise and relational care are not the same thing, and that both are necessary for care to be truly skilled.

The women in that hospital were grateful to have delivered safely. And they were also aware of what they had not received. Both things are true. Both things matter.

Listening to that gap is what research is for.

About the author

Peter Schindler, MD, PhD is an Assistant Professor of Medicine and Associate Program Director of the Community Health Center Family Medicine Residency Program at the University of Nebraska Medical Center. He practices at Winnebago Comprehensive Health System, OneWorld Community Health Center, and Nebraska Medicine. He completed a Primary Care Research Fellowship at McGill University and holds a BSN from the University of Wisconsin-Oshkosh, an MS and PhD in nursing from Emory University's Laney Graduate School, a Diploma in Tropical Medicine from the Liverpool School of Tropical Medicine, and an MD from the Medical College of Wisconsin-Green Bay. He is board certified by the American Board of Family Medicine. The Interprofessional publishes new essays every week at the intersection of medicine, nursing, and the clinical knowledge that lives between them.

Disclaimer. The views in The Interprofessional are Peter Schindler's own and do not represent the official positions of the University of Nebraska Medical Center, Winnebago Comprehensive Health System, OneWorld Community Health Center, Nebraska Medicine, or any other affiliated institution.