This was a qualitative study using the action research method to collect data. Participants were made up of midwives who were selected based on their experience and willingness to participate in the study.

The study was carried out in three hospitals selected purposively, notably Hospital 1, Hospital 2, and Hospital 3. Hospital 1 is a tertiary-level public hospital with a capacity of 852 beds, attended by around 22000 outpatients monthly. It is situated in KwaZulu-Natal (KZN) Province, Durban. Hospital 2 is also a public hospital located in the eThekwini health district. Both Hospital 1 and operated are by the Department of Health in KZN. Hospital 3 is a private healthcare facility and has a capacity of 204 beds. Durban is one of the four major cities in South Africa with a population of 3,120,282.

The study participants were made up of registered midwives with at least one-year minimum of experience. Registered midwives interested in the study were recruited from the three selected hospitals in Durban KwaZulu-Natal as follows: Hospital 1, Hospital 2, and Hospital 3. Twenty individual interviews and three focus group discussions were conducted. Two focus group discussions composed of six midwives each and one had five midwives. Nurses who were not midwives were not included in the study.

The sampling procedure was divided into two parts. Firstly, convenience sampling was employed to select the hospitals from which interviews were going to be conducted based on the hospitals’ responses to requests for research support. The inclusion criteria for hospitals were having functioning maternity and labour wards. Only three out of five hospitals allowed the researcher to collect data in their wards. Secondly, a research site manager assisted in identifying midwives meeting the requirements from the ward. After obtaining the list of names and contact numbers of potential participants, a random selection was made. The selected participants were encouraged to work collaboratively with the researcher. Participation in the interviews was restricted to a minimum of one year experience, however, there was no restriction to the number of participants during individual interviews. It was stipulated that individual interviews would be conducted until data redundancy is reached and no new information coming from the participants and that determined the sample size of the study. Three focus group discussions were conducted with 17 participants and 20 individual interviews were conducted with midwives during the study.

The instruments of data collection included an interview guide and focus group discussion. The interview guide had main major questions that would allow the researcher to probe further on matters related to birth preparedness. The initial plan was to conduct online interviews and FGDs. However, the removal of restrictions related to COVID-19 on gatherings paved the way for face-to-face interviews and focus group discussions. The data was collected in three selected hospitals in Durban KwaZulu-Natal, namely hospital 1, hospital 2 and hospital 3. Before proceeding with data collection, permission was obtained from sampled hospitals as well as approval from the Biomedical Research Ethics Committee (BREC) of the University of KwaZulu-Natal. Once on the field, the researcher ensured that participants were briefed on the study, made aware of their rights, and had the consent form signed before conducting interviews. During the interviews, the researcher took field notes as well as keeping a record of some observations. The individual interviews lasted between 15 to 45 minutes. All collected data were transcribed and coded subsequently.

Before proceeding with fieldwork, Ethical approval for the study was sought from the University of KwaZulu-Natal Biomedical Research Ethics Committee (BREC) protocol number: BREC/00002786/2021, along with the gatekeepers’ permission to allow the researcher to access the selected hospitals. The KwaZulu-Natal Department of Health (KZN-DoH) reference: KZ_202109_006. Participants were given an information letter shedding light on their voluntary participation in research and asked to sign an informed consent form as proof of their confirmation to take part in the study before starting the interviews. Also, the consent of participants for audio recording was obtained. Furthermore, they were informed of their right to withdraw from the study at any time, skip a question, and that they would not be inconvenienced in any way and this would hold true should they decide not to be part of the study or decide to stop.

Content analysis was employed to analyze the study data. (Kleinheksel, Rockich-Winston, Tawfik, Wyatt, 2020). During fieldwork, the content analysis helps the researcher to listen, reflect, clarify, and observe. In a qualitative study, content data analysis has six distinct stages. Firstly, in an attempt to re-establish the experience of the fieldwork, the researcher read the interview transcripts. They were reread to comprehend the meaning of the discussion in its totality. Secondly, it was planned to extract relevant information about the phenomena under investigation. Thirdly, it was planned to make meaning out of the phrases and arrange similar phrases to generate and classify themes. Fourthly, the themes were organized into groups. Fifthly, the experiences of the interviews were presented from the perspective of the participants. Finally, it was planned to send the document to the research supervisor for review and further comments.

Criteria, as set out by Lincoln and Guba (1985), were used to establish the trustworthiness of qualitative data. During face-to-face interviews notes were written and transcribed immediately after each interview to ensure credibility of the study. The interviews were audio-recorded, and then transcribed verbatim to ensure that all participants’ responses are captured appropriately. Following the transcription of the recorded interviews, participants were given a chance to review the transcripts and were asked to confirm the accuracy of information they gave during data collection. To ensure transferability, there was rich and thorough description of the research process and the research setting.

Demographic characteristics help provide crucial information for understanding events or communities as they have evolved. Factors such as age, socioeconomic status, and experience shed light on the attribute of people under investigation. These factors are essential for businesses, policymakers, organisations, and governments to have insights into the type of people or communities they deal with in order to make informed decisions. For instance, features such as age and experience of midwives do not only speak to their maturity and wisdom but also the extent to which they have been exposed to the events.

The study made use of focus group discussions (FGDs) and semi-structured interviews for data collection purposes. Three separate groups of midwives took part in focus group discussions (FGDs), two had six participants each, and one had five. A total of twenty midwives took part in individual semi-structured interviews as shown in Table 1 below. All the study participants reported being Durban based and were either married, single, or divorced. In terms of experience and age, the longest-serving midwife was also the oldest at 19 years and 54 years old, respectively. The youngest midwife was 27 years old and the least experienced was 35 years old and has been serving for 2 years. Their educational qualifications are as follows: Degree (4 years), National Diploma, and Diploma in nursing and Midwifery.

Birth preparedness is perceived as an important part of gestation in expectant mothers’ journey to labour. It was defined according to its effect and role in birth preparation. From the perspective of effect, birth preparedness is described as an anxiety-allaying process, it is a process within which healthcare workers need to prepare the mother for birth, and the way we can do that is through our health education and explaining everything that is happening to her every step of the way (Participant HCWs6). Taking into consideration its role, birth preparedness was defined as the process of preparation for birth which involves the follow-up and adherence of expectant mothers to antenatal classes. Birth preparedness helps expectant mothers to cope and deal with changes occurring in them. Expectant mothers are told about expected change so they may be able to distinguish the normal from the abnormal and assess whether what is happening in them is expected or unexpected. In other words, birth preparedness is a process characterized by mental, physical, and emotional preparation for birth.

Table 2 provides a list of subthemes and their respective themes.

In mental preparation, expectant mothers are taught about the different experiences of pregnancy, birthing options, and labour signs. Concerning different experiences of pregnancy, an attempt is made to show expectant mothers that they are different and the experience of pregnancy differs from one another. This can be observed among people belonging to the same or different socioeconomic status, family members, and even different parties. To make it more explicit, a participant highlighted that complications may arise during delivery or pregnancy, and expectant mothers need to be well aware of it (Participant HCWs7) . The possibility of spending more time than expected in the labour ward was mentioned by another participant as she said they need to know that labour is a process that may take more than a day before delivery comes (Participant HCWs9). Regarding birthing options, participants indicated that it is important for expectant mothers to be always ready to settle either for normal birth or C/section when they come into labour. (Participant HCWs 10). Concerning knowledge of labour signs, a participant highlighted that expectant mothers need to know what is going to happen in labour, what is labour like what are the first signs of labour, she needs to know what are the true signs of labour (Participant HCWs12). Also, they are encouraged to come to the clinic as soon as they have the first danger or warning signs of labour.

In physical preparation, the well-being of expectant mothers is perceived as an important component. The importance of physical well-being is acknowledged, and expectant mothers are encouraged to maintain good health and monitor vital signs. This can be achieved by taking medication consistently and monitoring fetal kick count at home. For instance, a participant highlighted that expectant mothers receive information during antenatal classes on the kind of foods required to enable baby’s growth when to take medications as well as on the importance of taking supplements (Participant HCWs2). Furthermore, visiting the ward before delivery is perceived as part of the preparation, it allows expectant mothers to adjust to the labour environment. It was also noted that the expectant mothers who have medical aid and those who can afford the bills in private insist on visiting the maternity wards first. The come for a tour as early in pregnancy they want to know everything concerning the environment long before their due dates (Participant 1, FDGs1).

In emotional preparation, expectant mothers are made aware of labour pain and how to handle it. They are told that pain is part of the birth process and it cannot be avoided. Its effect can be reduced by using some techniques taught by midwives. A participant reported that expectant mothers receive instructions on how to handle the pain and practice deep breathing exercises (Participant HCWs10). Besides this, it is possible to alleviate pain by taking some medications prescribed at the healthcare facility. Birth preparedness is an important and beneficial process for midwives, expectant mothers, and babies.

3.3.1 Birth preparedness

Participants acknowledge that preparation for labour is a crucial stage for every expectant mother. It was reported that a substantial proportion of expectant mothers are not ready when they come into labour. It was estimated that 90% of our patients are not prepared to deliver and they do not even understand how the pain, and labour start (Participant HCWs6). Teenagers are the most unprepared of expectant mothers (Participant 5, FGDs2). Unprepared expectant mothers make the task of midwives difficult. This ranges from prenatal tasks such as delivery to postnatal care. The unprepared, particularly teenagers, are scared to be checked how far they are dilated, they do not want to be put in a catheter or even touched (Participant 5, FGDs2) . Another participant highlighted that when asked about breastfeeding, their reply was I never heard about it before (Participant 1, FGDs3). Also, they are less cooperative. A participant reported that they have birth plans, expect everything to go as planned, and are not ready to accept any change or different birthing option (Participant 3, FGDs1) .

Birth preparedness is not only important for prenatal but also for postnatal stages and it is associated with some benefits. These include physical and mental preparation, less risky delivery, and reduced risk of negative outcomes. Physically and mentally, it helps expectant mothers to prepare for life changes in terms of sleep and eating pattern, which is going to depend on the baby’s pattern, right after delivery.

Regarding less risky delivery, prepared expectant mothers to know the expectation of healthcare workers and are less likely to do something that can endanger the safety of their babies during labour. They are inclined to reduce delays in obtaining healthcare. Also, they are more cooperative and more prompt to play their part during delivery compared to the unprepared. For instance, it was reported that the unprepared might get their babies distressed or even stuck because they do not know how to open their legs enough for the babies to be taken out (Participant HCWs5). This leads midwives to use forceps and be forceful in order to help them deliver.

Concerning the reduced risk of negative outcomes, it was reported that better preparation of expectant mothers tends to result in less negative outcomes such as postpartum haemorrhage which is common in the unprepared. It is worth highlighting that birth preparedness is made possible through the actions and interactions of both expectant mothers and midwives.

3.3.2 Actions and interactions strategies in birth preparedness

It was reported that midwives are part of the major role players in birth preparedness. Their contribution to birth preparedness is made through actions and interactions with expectant mothers attending antenatal classes and in the labour ward. These actions and interactions are used as a pathway to the success of birth preparedness. They revolve around topics such as different signs of labour, danger signs, counting baby’s kicks, breastfeeding, exercises during labour, breathing techniques, empowerment on how to deal with labour preparation, the importance of antenatal classes, family planning, and a healthy diet. Actions and interactions take place during antenatal classes and in the labour ward.

During antenatal classes, health education takes place in the morning. Expectant mothers attend either in a group or on a one-on-one basis. A participant reported that we sit and talk to the patient and give some health advice and whatever, we discuss signs of labour, what they need to know, and sometimes we tell them not to wait for pain because the water may break while there is no pain (Participant HCWs2). Sometimes, they are told the same message repeatedly. This is done on purpose since midwives are able to assess the level of birth preparedness of their audience, and all expectant mothers are grouped in one class. Also, they assume that expectant mothers come from other clinics where maybe they would have missed some information (Participant HCWs16).

An emphasis is placed on teenagers’ and non-teenagers’ expectant mothers’ well-being and this may lead midwives to engage in a one-on-one conversation. In general, those who have chronic conditions such as diabetes are encouraged to eat healthy as well as to adopt a healthy lifestyle. Topics such as family planning may not have something to do with birth preparedness, however, it is used to raise awareness about the health of expectant mothers. A participant highlighted that you cannot have a baby this year and the following year, you need to heal your wound. Hence, give yourself some time to heal (Participant HCWs8).

Besides verbal health education, midwives interact with expectant mothers in many ways. Firstly, expectant mothers are given pamphlets that can be read at home for a better understanding about labour. secondly, they are encouraged to count the baby’s kicks and bring the report on the next appointment for follow-up. Thirdly, expectant mothers’ files are checked when they come in the morning before screening to see whether they are up to date or not. This helps to ensure that all required tests were done and they are even asked some follow-up questions. Also, vital signs are monitored, they can even be palpated to ensure that the baby is growing well.

In the labour ward, on admission, the connection with expectant mothers is made by interviewing them and getting their medical history. In this regard, a participant highlighted the necessity of this connection as she said you have to build up a relationship or rapport with that patient because if you are open and communicating in a friendly manner, the patient is open to you. But most of the time in government healthcare facilities, we are busy that there is no time to give that personal touch to the patient (Participant HCWs5). For instance, fun things like plays can be used to get connected with an expectant mother. It is worth highlighting that, based on their birthing option, actions, and interactions with expectant mothers admitted to the labour ward may be different. For instance, actions and interactions, with totally unprepared expectant mothers booked for c/section, revolve around their birthing option. They are told about sedation and everything that follows, the pre and post-delivery process, breastfeeding, c/section, and what will happen in the theatre while preparing them a day before surgery. For normal birth, their cooperation is required in vaginal examination, which is described as the most challenging part of monitoring patients who will have a natural birth. Expectant mothers are told that the examination will be done four hourly in the ward and two hourly in the labour.

Participants identified a given number of factors that enable birth preparedness among expectant mothers. These include socioeconomic status, family support, support group, nurse-patient relationship, information sharing, employment and upskilling of midwives, and community involvement.

3.4.1 Socioeconomic status

In socioeconomic status, the level of education of mothers is instrumental in their understanding of what is at stake. It was highlighted that compared to the uneducated, educated expectant mothers are more prepared. They do not only rely on information received from healthcare facilities but they also conduct their search. They educate themselves by using all available information sources such as books, Google, and other platforms to learn more. After reading, they will always come back and ask questions and engage with us for more light (Participant 4, FGDs2). Also, they know what to expect since they understand what will happen (Participant 3, FGDs3).

3.4.2 Family support

Concerning family support, for instance, a married woman has the advantage of either planning or preparing to welcome the new baby along with her husband. This prompts her to be open to asking questions in an attempt to know more about what can be done next. Sometimes, she has been looking forward to giving birth a long time ago and is ready to go to any extent to be prepared as well as get her partners involved. A participant reported that some expectant mothers leave all purchased items required for labour at home on purpose and want their husbands to come to drop them off at the labour ward (Participant HCWs20) . Furthermore, based on family support, it is possible to assess the patient’s need for a mentor. This helps her to be mentally prepared for the whole time of pregnancy until delivery. Family support is mostly needed by first-time mothers and it allows them to cope with their babies.

3.4.3 Support groups

In support groups, expectant mothers come together as a group to talk about their experiences. A participant indicated that you can be with other moms who have been through the experience before, who can share the experiences with you, good and bad because you do not know what your experience is going to be like as a mom during labour (Participant 1, FGDs1). Hence, united in the same fate, expectant mothers can support and comfort each other.

3.4.4 Nurse-patient relationship

Regarding nurse-patient relationships, working toward improving the relationship between nurses and expectant mothers is put forward as one of the enabling factors. The improvement consists of making expectant mothers feel comfortable, considerate as well as involving them in decision-making. It is important for midwives to treat well expectant mothers and avoid insulting them (Participant 6, FGDs2). For instance, teenagers are encouraged to forget their age and see themselves as expectant mothers. A participant stated I am here to teach you as a mother giving birth, my business is not to know why you fell pregnant, when you fell pregnant, who made you pregnant, what we want to deal with is the situation in front of us (Participant 4, FGDs3).

3.4.5 Information sharing

Regarding information sharing, the implication of both midwives and expectant mothers in birth preparedness is crucial. Midwives have more experience in how to educate expectant mothers on birth preparedness, and sharing information in this regard makes a significant contribution to the process of birth preparedness. We give health education every morning and every time we interact with them, we share information which will makes it easier for them to understand the process of pregnancy and how important is for them to always be prepared (Participant 4 HCWs).

Another participant mentioned that we try our best to share information, yes, we teach them, but some women say my doctor said this and that, they are not really interested in our teachings. But you see those who pay attention to us they are prepared in terms of what to expect when giving birth (Participant 3 HCWs, Participant 1 FDGs1).

3.4.6 Employment and upskilling of midwives

With the employment and upskilling of midwives, the expectations placed on midwives in terms of tasks to perform are overwhelming. This makes it difficult for them to attend to every expectant mother. We are short staffed, the company is not employing enough midwives, it is difficult for us to give enough attention to each expectant mother admitted with us (Participant HCWs 16, Participant 1, FDGs3). Another participant said there is no time for us to educate ourselves anymore, they don’t even send us for training so that we can be updated (Participant 10 HCWs).

3.4.7 Community involvement

From the community side, since expectant mothers tend to miss antenatal classes, the involvement of the community is perceived as a better way of reaching a substantial proportion of them. This can be done at the school and community level. In schools, the teaching curriculum should include lessons or modules teaching or educating learners about birth preparedness. This means children will learn from school, talk about it at home, grow with it, and they will know how to be prepared when they become pregnant (Participant HCWs9). For the community, since it is difficult to provide health education to expectant mothers attending healthcare facilities, it can be done by entrusting some people with that responsibility. These people will go into the community and educate about birth preparedness (Participant HCWs18). This strategy will make a big difference in preparing community members because they will be able to get information on birth preparedness instead of coming with nothing to the clinic.

Participants identified some factors perceived as hindrances to birth preparedness among expectant mothers. These include finance, heterogeneity, staff shortage, language barrier, lack of family support, lack of interest, cultural beliefs, and confusion.

3.5.1 Finance

Concerning finance, it is associated with two distinct financial constraints, notably the unaffordability of bus fare and baby items. The lack of bus fare was reported as one of the reasons preventing expectant mothers from attending antenatal classes. It was reported that paying for bus/taxi can be imposed or self-imposed. It is imposed when the nearest healthcare facility is far from the place of residence and requires transport and self-imposed when a patient chooses to attend a farther healthcare facility. A participant expressed concerns over this issue and said I do not know why we are getting patients from areas where there are clinics and hospitals. When asked, they say we have moved and then they fail to come next visit, they will come in labour because of financial constraints (Participant HCWs1). Besides the inability to afford the commuting cost, it was challenging to buy both their babies and the items required for labour. It was said most of our patients do not have money, they cannot even afford items like clothes for the expected new born (Participant HCWs2).

3.5.2 Heterogeneity

In heterogeneity, although expectant mothers come together, it is difficult to talk to them as a group. Differences among them make it difficult for them to be addressed as people who belong to the same group. Firstly, their age labels represent a serious hindrance. I cannot speak to a 40 years old woman the same way I speak to a 16-year-old, a 16-year old will not listen to you the same way a 40-year-old does since the 40-year-old is more mature for certain things (Participant HCWs4). Also, grouping teenagers cannot be done because patients need to be segmented in a particular way in the ward. Secondly, HIV and non-HIV patients cannot be addressed in the same way, because you will be diverging information to other patients (Participant HCWs4). Hence, everybody cannot be muted or put on the same level.

3.5.3 Staff shortage

Regarding staff shortage, it becomes difficult for the available staff to have time to do health education or to spend much time with expectant mothers in a one-on-one conversation. Midwives find themselves compelled to clear long queues rather than being involved in a one-on-one consultation with each expectant mother. Furthermore, it is witnessed a decline in the standard of nursing care to the extent that it becomes impossible to perform some of the tasks as it was in the past. For example, we could massage your back but now, we cannot do that, we do not have time for that (Participant HCWs14). Sometimes there is only one of us in the ward, you cannot spread one nurse between 31 patients (Participant HCWs4). At present, one nurse is doing the job of many people, this has become a serious challenge. The only thing that we get to do much is the breastfeeding latching of babies (Participant HCWs13) . Another participant added , shortage of midwives is too much here. Then they expect quality care like really! So, we end up with complaints from the mothers after they are discharged, they send emails to management (Participant 4 HCWs).

3.5.4 Language barrier

With a language barrier, depending on their background, expectant mothers attending antenatal classes speak different languages. Some of the languages mentioned are French, and Portuguese. A participant provided further light as she said; s ome of them speak only French, others Portuguese only. It is a serious challenge since some patients do not know how are you? Was the baby moving? You literally cannot speak to them at all and I think they will not even be able to read (Participant 2, FGDs2). In the past, they used to call another patient who speaks the same language to interpret but this breaches the confidentiality clause (Participant HCWs5). It was also noted that the use of medical terms represents a challenge to expectant mothers, even English speakers.

3.5.5 Lack of interest

Lack of interest, some expectant mothers are not interested in antenatal classes and this prevents them from being prepared. Despite their lack of interest, they attend antenatal classes for some reasons. Firstly, the attendance is done for the sake of doing and/or securing a space for delivery. Secondly, the aim is to collect medication and have the vital signs and the baby checked. Thirdly, they do not even want to learn anything no matter how many classes they go to, they are not interested (Participant 1, FGDs1). Fourthly, they do not benefit from any support from the fathers of their babies. According to a participant only 20% of expectant mothers are possibly married and live with their partners. The rest is made up of unmarried and teenagers who are emotionally immature (Participant HCWs1). Fifthly, the pregnancy is not planned and mothers avoid being much involved in birth preparedness, they do not seek to know more about it. Finally, most expectant mothers do not book antenatal timelessly and come late in the morning and hurry to go back home, therefore, they miss health education (Participant HCWs15). Sometimes they can be present but end up sleeping during classes (Participant HCWs7).

3.5.6 Cultural beliefs

Regarding cultural beliefs, some expectant mothers grew up witnessing pregnant women taking traditional medications to prepare for labour. This prompts them to perpetuate this practice and when asked questions about it, they reply because my mother and grandmother said this is what we have to do at home (Participant HCWs11). Also, it was mentioned that most teenage expectant mothers (aged 14, 15, and 16 years) refrain from asking questions during antenatal classes to avoid disrespecting their elders. In other words, asking questions related to pregnancy is perceived as a form of disrespect because of their young age.

3.5.7 Confusion

Considering the confusion, it was indicated that expectant mothers receive advice on birth preparedness from more than one source which leads to confusion. A participant made it clear that some expectant mothers are advised by their mother-in-law, search for advice on Google, and get confused when they meet with midwives at the hospital (Participant 3, FGDs1) . They tend to focus more on negative and wrong information read on social media or from their friends (Participant 6, FDGs3).

There are some limitations inherent in this study. Firstly, it took place in three settings that were not representative of all midwives of Durban and even the province. Secondly, the study did not include participants from other parts of the country, notably provinces. Thirdly, the study did not explore the perspective of other women living in Durban who did not attend antenatal classes at these selected hospitals. Finally, the results of this study cannot be generalized to the entire pregnant population of the country since the sample was drawn on a purposive basis.

The successful outcomes of birth preparedness require the implementation of some strategies which are as follow. Firstly, the employment of new midwives and the upskilling of those who are currently employed is thought to release pressure and result in giving them more time to focus on expectant mothers. Secondly, family and partners should be allowed and encouraged to attend antenatal classes. Thirdly, midwives should attend workshops and being taught how to communicate with patients, how to be youth friendly, how to interact with teenager expectant mothers, what to teach and how to prepare for birth during antenatal classes. Finally, to install in the waiting room a TV or something that expectant mothers can watch that gives information on birth preparedness.

This study received full ethical approval from the Biomedical Research Ethic Committee (BREC), from the University of Kwazulu-Natal, with reference number (BREC/00002786/2021).