Similar to pregnant women in another study , midwives in this study believed that the supine position was the best, most helpful, and best-known birthing position. Most of the midwives believed that the supine position benefits the foetus, mother, and the midwife. They also believed that supine was beneficial to the mother as it made her feel relaxed and allowed her to easily push the baby out because it conserved her strength. Midwives and postnatal mothers also believed that the supine position made it easier for the midwife to conduct deliveries because it allowed them to observe the birth process while assisting the mother during the second stage of labour. These findings are in line with a study done in the United States which concluded that women are encouraged by their health care providers to assume the supine position, in order to allow providers the ability to conduct a delivery more conveniently . Findings of our study are also consistent with a study done in Canada, which revealed that half of the mothers who gave birth in the hospital assumed the supine position . However, researchers have reported that in non-western cultures, in which, parturient mothers were giving birth in an upright position while supported from the back, the supine position was not encouraged [27,28,29]. This suggests the social nature of giving birth as well as a respect for the physiologic birth process in earlier times.
Midwives and some mothers in this study thought that the supine position is the most advantageous and helpful to the mother. The findings are similar to another study by Okonta , which reported that all pregnant women who were surveyed preferred the supine position for childbirth. This preference is contrary to evidence indicating that upright positioning is most beneficial to the mother and infant. Lawrence and colleagues reported that the upright positions such as sitting, squatting, leaning forward or kneeling positions were more often assumed and revealed no any harm to the mother, baby or labour outcome . Other findings from Sweden reported that upright positioning, when assumed in the second stage of labour, is associated with increased sagittal outlet and interspinous diameters compared to supine positioning . A preference for the supine position may be due to a lack of knowledge about its advantages and disadvantages among midwives during their professional training.
Both mother and midwife participants in this study believed that other birthing positions, such as lateral and squatting positions, were not suitable for the birthing woman. Therefore, few postnatal mothers changed birthing positions to ease the pain that they felt while in the supine position. Midwives thought that alternative positions were not good despite evidence that points to increased benefits associated with these positions compared to the supine position. Interestingly, the lateral and the upright positions have been effective in correcting malpositioning of the foetus, contrary to what study participants perceived. In addition, the lateral position has been found to be effective in relieving maternal exhaustion due to prolonged labour and also increases the rate of perineal intactness .
Parturient mothers assumed the position preferred by the nurse-midwife attending the delivery. In line with findings from this study, a study done in Canada on the humanization of birth found that mothers were reported not to benefit from decision making in the process of labour [26, 30]. This lack of involvement of women during the birthing process is likely to make some women feel out of control during childbirth and unable to make informed choices . Only one mother in this study reported that she was given an opportunity to choose a position during birth. As reported elsewhere, health care providers made most of the decisions surrounding birth care, which were often quite directive . Another study  found that the nurse-midwives’ choice of birthing position for the parturient mothers was based on their custom. Nurse-midwives chose the position that was easiest for them to carry out their professional procedures and the parturient mother was left passive. Searle  reported that health care professionals, including midwives, significantly influence birthing positions of parturient mothers. Childbirth had historically been viewed as an illness rather than a natural process. Consequently, this historical construction has reduced mothers to the role of the passive recipient rather than active participant in decisions regarding personal health information . Elsewhere, researchers have reported that if mothers are allowed to choose their preferred birthing position, they would assume alternative birthing positions .
Consistent with other studies , the nurse-midwives in our study reported that mothers who had delivered several times or had had previous deliveries in the village challenged them by insisting on assuming birthing positions other than supine. This attitude of the mothers was perceived negatively by nurse-midwives, who termed it ‘uncooperative,’ as the mothers’ wishes contradicted the views of the nurse-midwives. The nurse-midwives responded by encouraging them to assume the supine position instead, as taught during their training . Another study reported that mothers who gave birth at home with traditional birth attendants retained control over their birthing positions, while at the hospital, they feared unfamiliar birthing positions, including the supine position . In Bangalore, mothers who maintained an upright position (supported sitting position) in the second and third stages of labour also challenged health care professionals to promote evidence-based practices by shifting away from using the routine supine position during delivery .
When women are empowered to make their own choices about their birth process, including birth position, it helps to build confidence and promote autonomy. It is imperative that the birthing woman is respected and that her choices are supported with unbiased information and evidence about best practices [36, 37]. A study in Malawi reported significant improvement in parturient mothers’ overall satisfaction with their care simply because they were informed about the different birthing positions and given a choice . To further support this, another study in Ghana revealed that parturient mothers appreciated a competent midwife who acted not only as a care provider but also as a labour companion, thereby empowering mothers to take the lead while also receiving relevant information from the midwife. Informing women about different birthing positions is one way of promoting the empowerment of mothers and has been found to positively influence the perceptions of mothers toward the birthing process . Overall, shared decision-making brings positive experiences for both parturient mothers and their health care providers and increases mothers’ satisfaction with the labour process .
This study revealed that midwives primarily conducted deliveries using only the supine position. Most nurse-midwives and postnatal mothers did not know alternative birthing positions. Nurse-midwives also acknowledged not being able to conduct deliveries using alternative birthing positions given their lack of experience as well as knowledge. Their primary concern was feeling incompetent to assist mothers in non-supine births due to insufficient training during their professional courses as well as the increased pressure that comes with potential obstetric emergencies. As indicated in the International Federation of Gynecology and Obstetrics (FIGO) guidelines, increased competency of health care providers and adequate equipment/space would facilitate the choice of birthing position by mothers. The use of the supine position during birth has been promoted through midwifery training and has now become a ‘habit’ that continues to be practised without evidence to support it as the ‘best’ birthing position [13, 32, 36].
Throughout the study, it became evident that midwives’ practice of assisting women to use the supine position during birth was greatly influenced by the biomedical model. Midwives, much like their physician colleagues, often believed that every woman who seeks birth care at a health facility is “sick” and lacks knowledge concerning health care or treatment. Based on this assumption, women are rarely provided with a chance to choose their birthing position during labour and delivery. Moreover, birth is frequently dominated by interventions that hinder the natural progress of childbirth . The practice of not giving women any choice in their own birthing process may influence women’s birth-seeking behaviours, as many women in Tanzania still give birth at home assisted by unskilled personnel .
Nurse-midwives often take the lead of the birthing process, which should include a choice of birthing position used by the birthing woman. In order to promote choice, autonomy, and empowerment of the mother, midwives must actively provide women with information concerning alternative birthing positions. Holistic care must be a priority while caring for a mother in labour. Cooper  highlights that the individualized, holistic care provided by community midwives should be translated into health care facilities as a way of improving person-centred care .
Some postnatal mothers in this study reported knowing different birthing positions and others reported using them in their previous deliveries. However, midwives were resistive to accepting mothers’ choices, especially if alternative positions were mentioned. These findings are inconsistent with a study done in Sweden that outlined how health care providers must promote evidence-informed care and centre the mother as an agent in her care to improve perceptions of mothers’ on the birthing experience . In this study, midwives’ reasons for not promoting alternative birthing positions included the belief that they were unsafe for the mother and the foetus, and not favourable to the management of labour for midwives. In addition, midwives in Tanzania are not taught alternative positioning in their training. As a result, mothers had little room to choose their preferred birthing position due to their view that the midwives were the experts and mothers in childbirth needed to follow their directives.
While this study was conducted with rigour and provides important insights into the perceptions and experiences of women and midwives on birthing positions, the difficulties involved in translating the interviews should be acknowledged. The analysis of the semi-structured interviews and FGDs were completed in English from translated transcripts. The transcripts were verified by co-authors fluent in Kiswahili to ensure accurate translations, and all codes and themes were discussed among the researchers by reviewing the original Kiswahili transcripts. Additionally, after every interview, researchers had the opportunity to listen to the audio-recorded interviews, reflect on the interview sessions and gather additional information in the reflection sessions, all of which were used during analysis to verify the interpretation of themes.
Postnatal mothers were interviewed within the hospital setting far from the postnatal ward. Having interviews in the hospital setting may influence how mothers reported their experience of childbirth. However, all attempts were made to ensure confidentiality and study participants were informed that their responses would not be shared with their healthcare providers. The aim of this study was not transferability of findings, but rather to gain an understanding and shed light upon why the supine position is commonly assumed by women during childbirth in the health care facilities in Tanzania, despite the fact that other and better alternative positions exist.