Being in limbo: Women’s lived experiences of pregnancy at 41 weeks of gestation and beyond – A phenomenological study

The World Health Organisation (WHO) has defined post term pregnancy (PTP) as lasting 294 days or longer, i.e., gestational week (GW) 42 + 0 days, from the first day of the last menstrual period [1, 2]. However, there is no consensus on this definition. Studies analysing the risks and management of PTP also include pregnancies from ≥41 GW, i.e., late term pregnancy. There is no known aetiology of PTP. Some identified causes are foetal anencephaly, foetal adrenal hypoplasia or insufficiency and placental sulphates deficiency. Risk factors include primiparity, advanced maternal age, maternal obesity, heredity, previous PTP and a male foetus [3–7].

The prevalence of PTP is approximately 5-10% [8] but varies between countries. Factors that influence prevalence are population characteristics such as maternal age, rate of preterm birth e.g. <37 GW, interventions, induction of labour, availability of routine ultrasound pregnancy dating, the number of primiparous women in the population and pregnancy surveillance routines [9]. PTP prevalence varies between 0.4% in Austria and 8.1% in Denmark [10–12]. The reported PTP prevalence in Sweden was 6.9% in 2013 [13]. Previous research has focused on the prevalence and risk of perinatal complications in PTP. Such complications increase the risk of foetal mortality, meconium aspiration syndrome (MAS), umbilical cord complications, asphyxia, pneumonia, sepsis, convulsions, shoulder dystocia, traumatic injuries, peripheral nerve damage and neonatal encephalopathy [5, 14, 15]. Furthermore, developmental delay [16], increased rates of obesity and early markers of metabolic syndrome have also been reported in post term children [16–18]. Maternal complications in PTP are puerperal infections, postpartum bleeding, disproportion, labour dystocia, emergency Caesarean section and cervical lacerations [5].

Due to the increased risk associated with PTP, a solution would be to suggest induction of labour before the pregnancy becomes post term. However, most randomised controlled trials (RCTs) comparing induction with awaiting the spontaneous onset of labour, with or without foetal surveillance, are small and of poor methodological quality. An HTA meta-analysis including 17 RCTs (n = 7223 women) [19], and recently published systematic reviews including 31 RCTs [20] and 157 RCTs [21] showed a lower perinatal mortality rate in the induction group, fewer cases of MAS and either no difference or a lower risk of Caesarean section after induction, compared to spontaneous labour. A methodological problem in individual studies and systematic reviews is that critical outcomes such as perinatal mortality and hypoxic ischemic encephalopathy are rare [22–24]. Thus, very large studies are needed to address such outcomes. Thus, there is no consensus as to the optimal time for labour induction or the optimal method of antenatal surveillance. However, according to guidelines in Norway (Norwegian Directorate of Health) [25], Denmark (The Danish Society of Obstetrics and Gynaecology, DSOG 2011) [26], UK (The Royal College of Obstetricians and Gynaecologists, RCOG) [27], USA (The American College of Obstetricians and Gynaecologists, ACOG) [28], and Canada (The Society of Obstetricians and Gynaecologists of Canada, SCOG) [29], induction should be initiated between GW 41 + 0 and 42 + 0.

It is well known that women’s experiences of childbirth constitute an individual, complex life event, related to the outcome for the child and the mother [30–32]. Studies reveal that women’s anxiety and worries increase when the pregnancy extends beyond GW 41 + 0 [33, 34]. Three cross-sectional studies [31, 35, 36], one RCT [37], one cohort study [31] and two qualitative studies [38, 39] all discuss experiences of induction of labour. Two cross-sectional studies from Sweden with 1111 and 936 women, respectively [31, 36], showed that induction of labour, irrespective of the cause, was associated with a more negative experience of childbirth. This finding is not supported by a study from Nigeria (n = 252 women) [35] and an RCT from Norway (n = 508 women) [37], which demonstrated that a majority of the women expressed satisfaction with the induction process. Only one RCT assessed women’s experiences of induction or expectant management policy (n = 508 women) [37]. At the time of randomisation, 74% would have preferred induction if given the choice. The majority of the women (84%) who were induced had a positive childbirth experience. Nevertheless, induction led to a more intensive labour. Studies have showed that women lack information and are thus unable to make an informed decision about the induction process [37–39].

To date there is only one interview study of women’s experiences of a PTP. This study found that the focus on medical issues and the categorisation of the pregnancy based on medical statistics lead to the women feeling less involved during their PTP. The women described a feeling of being pathological patients and expressed a desire to be induced earlier to avoid stigmatisation by relatives and friends [40]. Thus, there is a need for more research about women’s experiences of a PTP. The aim of this study was to describe women’s lived experiences of a pregnancy ≥41 GW.

A qualitative study with a phenomenological reflective lifeworld approach, as described by Dahlberg et al. [41] was conducted in order to illuminate the essential meaning of healthy women’s lived experiences of an expected normal pregnancy at ≥41 GW. A qualitative method is applied when there is limited knowledge of the phenomenon under study and can be particularly valuable for describing a phenomenon from the woman’s point of view. Reflective lifeworld research is an empirical method for research based on the work of Husserl, Gadamer and Giorgi [41]. The phenomenological approach is grounded in lifeworld research and used to describe and understand individuals’ experiences of different phenomena [41]. Lifeworld research with a phenomenological approach requires openness to the phenomenon on the part of the researchers, who must bridle their own preunderstanding, which includes knowledge and personal experiences [41]. The phenomenological approach was deemed most suitable for gaining a deeper understanding of PTP. The strength of this approach is that it provides a possibility to delve more deeply into the nuances and variations of a specific phenomenon. Variations were reached by interviewing women with different background, age, and parity.

In Sweden midwifes are the primary care givers for a healthy woman with an expected normal pregnancy, during pregnancy, labour and post-natal care. If complications occur during pregnancy and labour, an obstetrician will assume the main responsibility for the care. Antenatal care is normally provided by a midwife at a primary health centre. When the woman reaches GW 42 + 0 an appointment is arranged at the local hospital for induction of labour, where a hospital midwife will take care of the woman. Hence, there is a gap in the care chain, which can affect the information provided to the woman and her state of mind.

The present study was performed at an antenatal care unit in Gothenburg, Sweden, and an antenatal unit in a suburb of Gothenburg from August 2013 to September 2014. The inclusion criteria were a woman with an expecting normal single pregnancy in GW 41 + 0 to GW 41 + 6. Midwives gave eligible women oral and written information about the study at a regular check-up/appointment at their antenatal care unit. If the woman was interested, the midwife sent the woman’s telephone number by e-mail to the first author (AW), who in turn contacted the woman by telephone approximately 2-5 days before the interview. AW then explained the study in more detail and if the woman was still interested in participating, a time and place for the interview were arranged. The women received both oral and written information from the researcher, were informed about the purpose of the study and about the voluntary nature of participation. They were assured that the data would be treated confidentially and that they were free to withdraw at any time. The women in turn gave their written consent before the interview. Fourteen women were interested and booked for an interview but four women went into labour before the interview. The interviews were conducted at the antenatal unit or in the home, in accordance with the preference of each woman. An in-depth interview technique [42] was employed in order to create a relaxed, trusting and open atmosphere aimed at enabling the women to express their lived experiences of pregnancy ≥41 GW. There was an option to provide further support, but this was not requested by any of the participants. The following open-ended question was used: Can you tell me about your experiences of 41 completed GW? Follow-up questions were posed to gain a deeper understanding such as “can you describe more”. All interviews were conducted by the first author (AW), lasted between 25 and 50 min and were audiotaped and transcribed verbatim.

Ten women participated in the study. They were all married/cohabitating and varied in age from 23 to 37 years (mean 30.5 years). Three women had primary and secondary school degrees and seven women had university degree. All women were satisfied with their workplace/profession. Eight women were expecting their first baby and two women their second. All participating women spoke Swedish.

The essence of the phenomenon of women’s experiences of a late term pregnancy was described as being in a state of limbo, a void characterised by contradiction in relation to time, giving birth and the condition. Contradictions in connection with waiting evoked a negative feeling, as well as a form of restlessness, implying difficulties with simply being and taking each day as it comes as well as a sense of irritation and frustration. However, an advantage of the delay was gaining another day before the birth, which was sometimes experienced as positive. In their state of limbo, the women were more easily influenced by people around them, while in turn influencing other. There was also a feeling of insecurity concerning the body’s ability to give birth, which could increase due to opinions and advice from others. There was a belief that the child would arrive when it was ready, but that it preferred to remain in the womb. This entailed a contradiction in that the women did not want the labour to begin too quickly due to consideration for the unborn child, while at the same time they longed for her/his arrival.

The temporal contradiction implied that time passed both slowly and quickly. The estimated time of birth had passed, implying days and weeks that should never have even existed. The body was ready but the child was not; the body and child were not synchronised. Being in a temporal contradiction mainly implied negative feelings, even if initially this period was considered normal and had no significant effect on the pregnant women. As the days passed, more negative thoughts arose, despite the fact that the feeling about the last days of pregnancy and birth was basically positive. They found that just being was difficult, which in turn made them frustrated about the delayed birth.

The contradiction in relation to giving birth involved not only the will to give birth, but also trust and a desire to wait until the unborn child was ready. Thoughts became more negative, although positive thoughts and feelings still remained, including a sense of trust in the body’s ability to begin birth. The women were surprised by their own contradictory thoughts. The desire for a natural childbirth with a spontaneous labour onset began to change and they shifted from a positive view of trusting the body to initiate childbirth to mistrusting their bodies. Thoughts of inducing the birth began to arise, which included anxiety about their inability to achieve a natural birth without being induced, even in any future pregnancies.

Contradiction in relation to the women’s condition meant that healthcare professionals focused solely on the expected due date, while at the same time the women felt neither seen nor acknowledged by them. The due date dictated the planning of the visits to the midwife and the time for an eventual induction of labour, leaving no place for acknowledgement of the women. The essence can be further described by five constituents: “negative feelings and thoughts”, “difficulty associated with waiting for labour”, “unmet expectations”, “seeking alternative sources of information” and “the influence of others”.

The main findings in this study were that the pregnant women who had passed GW 41 + 0 felt that they were left in limbo, a void characterised by contradictions related to time, giving birth and the condition.

Being in limbo meant that the women experienced their existence as dominated by negative feelings that increased over time. Eri et al. [43] revealed that women moved into a “waiting” mode and a state of constant physical alertness around the due date. However, in our study this “waiting” changed in a negative way over time from trust in to distrust of the body’s ability to give birth. Earlier research has highlighted the importance of supportive professional encounters during pregnancy which women can develop trust in the capacity of their own body and feelings of control [32, 44]. Therefore, the midwife has a central role in supporting these women in trusting their bodies during both pregnancy and birth. During the prenatal and the natal period, greater continuity of care, woman oriented communication and a personal approach with enough time for each woman could enhance the care [45–49].

According to the findings of this study, the women wished labour to start spontaneously and during the pregnancy they trusted their body to achieve just that. However, after GW ≥41 they started to doubt their body’s capacity, which was mentally exhausting. At the same time, they were aware that very few women actually give birth on the estimated date of delivery. However, even though they knew this intellectually, it was difficult for them to ignore the negative feelings that arose. This is supported by previous research [17, 45] that also revealed that women in a late term pregnancy can suffer from stress and worry. The women experienced how healthcare during pregnancy was planned until the estimated date of delivery and were therefore surprised when visits, tests and examinations proceeded as usual after the estimated date of delivery. Ayers et al. [17] demonstrated that focus on the estimated date of delivery may decrease if antenatal care professionals give the women the latest instead of the estimated delivery date. This means that if the woman has not giving birth by the latest date, she will be induced. This might be a good strategy for diverting the focus away from the estimated delivery date. This strategy should be complemented by a greater interest in the woman’s experience. Previous research has revealed that seeing the woman and allowing her to participate is important for enabling a feeling of control during pregnancy as well as reinforcing her trust in the ability of her own body to manage pregnancy and birth [44, 50]. This will hopefully prevent the feeling of being in limbo by promoting more positive emotions and greater trust in the body’s ability to give birth.

The state of limbo made “just being” difficult for the women, as they experienced a loss of control over their body, the pregnancy and the birth. However, losing control of the situation was also positive as they learned to accept that they could not control how or when labour would begin. Feelings of control have been described as important for a positive birth experience by Bondas and Eriksson [45]. The challenge for healthcare professionals is to understand the generation of women who are now giving birth and whether there is a difference compared to 10-15 years ago. Today social media play an important role in influencing the women. Lundgren has previously demonstrated the importance of individual support during pregnancy and birth for helping the women to feel secure [44]. It is possible that women who search for and find information via social media require more individual support rather than more information.

Our study shows that the women sought support from their midwives but experienced a lack of acknowledgement and support, as the midwives tended to define overdue pregnancy as normal, thus failing to confirm the women’s experiences. However, women reported lacking such support during induction of labour and described care without caring [39], which is also consistent with the experiences of pregnant women with a systemic disorder and women with pregnancy-related pelvic girdle pain [51–53].

Understanding the Swedish maternity care system is of importance when interpreting the findings and it is necessary to point out that in Sweden there are different care providers for antenatal care and in the hospital. This can explain the experience of a gap in the care chain, as no extra check-up of either the woman or the unborn child takes place during this period. Continuity of care has been shown to influence patient satisfaction [54]. This lack of continuity of care can strengthen the sense of being in limbo. One question for further discussion is whether pregnant women should be offered a meeting with a professional from the hospital/delivery ward to receive information about the induction of labour in order to ensure a feeling of security and preparedness to give birth.

Although the women stated that their bodies were ready for labour, they did not know whether the baby was ready to be born. They wished that labour would start naturally but knew that it would be induced 2 weeks after the estimated date of delivery. They thought about a possible induction and felt it had been decided that labour would be induced if it did not begin spontaneously. Previous research has shown that women with post term pregnancies believed that neither their body nor the foetus was ready for birth [38]. The situation of these women could be improved by greater continuity on the part of the healthcare professionals during the prenatal period, woman centred communication and a personal approach including sufficient time devoted to each woman [45–48].

This study reveals that women who had reached GW 41 lacked information about care and management during the final days of the pregnancy. Dissatisfaction with antenatal care, lack of information and pregnant women’s experiences of not being taken seriously have been previously described [47]. In addition, the following prenatal care outcomes have been found to be important: reducing pregnancy-related stress and worries; developing confidence and knowledge to improve health; preparing for labour and birth; having supportive relationships and participating in decision making about the induction process [38, 49]. These factors provided greater satisfaction and a better birth experience [55]. Lack of information led to the women searching for information on the Internet [56–58]. However, our study indicates a risk that discussions with relatives, workmates and friends on the Internet only serve to intensify the pregnant woman’s feelings of uncertainty and fear, rather than providing relief. This was also found in a published article from Denmark were the informants experienced that people around them had a negative influence in PTP [40]. Nevertheless, the women in our study expressed that the information they found on the Internet was positive in that they understood that they were not alone in experiencing negative feelings due to passing the estimated date of delivery. It is essential that healthcare professionals guide pregnant women to high quality web-based information and take time to discuss it at antenatal visits [58].

Women’s experiences of pregnancy at ≥41 GW can be understood as being in a state of limbo, a time of unexpected waiting. The time of waiting consisted of contradictions related to time, giving birth and their condition, with increasingly negative feelings and mistrust of the body’s ability to give birth. The contradictions became more evident as the pregnancy progressed, especially their mistrust to the body’s ability to start the labour. When in limbo the women were kept waiting without sufficient information and support from their midwives, which meant that they had to deal with uncertain information from the Internet on their own. Without information about PTP the women sometimes had to trust the advice coming from relatives and other people close to them.

It is vital that these women are seen and acknowledged by midwives at antenatal clinics, in addition to being asked how they experience waiting for delivery. It is important that information on the management of the pregnancy and upcoming labour provided at the antenatal unit and the maternity ward is consistent. Offering an extra visit to the antenatal clinic can be a means of reducing worry and the feeling of being in a state of limbo. Midwifery support should be based on trust, confidence, familiarity, mutual respect, shared decision-making and good communication. The study did not examine what would have changed women’s experiences and whilst it is useful to discuss the implications of the findings for practice, more research is needed to know which aspects of care could be improved.