4.1.1 Research questions

4.3.1 Quality appraisal

The quality of the included studies was appraised using the mixed-methods appraisal Tool (MMAT) (Hong et al., 2018). The MMAT allows a judgement of the methodological quality of studies for various research designs (qualitative, quantitative, and mixed-methods studies). One study was judged as being of low quality. However, it was included because of its relevance to the research questions. Table 2 summarizes the included studies using MMAT criteria.

4.4.1 Data extraction

A data extraction form (see Table 3) was used to extract the data from the reviewed articles, including the study description, methods, and results. Thematic analysis was used to analyse the data for factors considered facilitators or barriers to developing supportive relationships. This involved reading the articles, searching for meaningful ideas, creating codes, identifying themes, organizing the themes, and naming them concisely to make sense for the reader (Braun & Clarke, 2006). Three main themes and nine sub-themes were generated (see Table 4).

4.5.1 Study characteristics

Two studies were conducted in the United States of America, three in the UK, two in Sweden, one in Japan, one in East Africa, four in Australia and one in NZ. There were 762 participants in the reviewed studies, including 450 midwives, 78 maternity nurses, 172 child-bearing women and 101 mothers. Of the participating women (i.e., 273 child-bearing women and mothers), 22 participated in the studies during pregnancy, 17 were in either the pregnancy or postpartum period, 234 were in the postpartum period and one was in a neonatal intensive care unit (Shimizu & Mori, 2018).

5.1.1 Demonstrating trust and respect

Six qualitative studies (Bradfield, Hauck, Duggan, et al., 2019; Bradfield et al., 2019a, 2019b; Madula et al., 2018; McInnes et al., 2020; Menage et al., 2020) described trust and respect as a facilitator of developing supportive relationships with women. In this review, ‘respect’ refers to how midwives differentiate the boundaries between professional and personal relationships, including accepting women′s choices (Nursing and Midwifery Board of Australia, 2018). “Trust” is defined as the part of a partnership with a woman that maintains equality and sharing (International Confederation of Midwives, 2017; Nursing and Midwifery Board of Australia, 2018).

Midwives stated that trust promoted the building of supportive relationships with women (Menage et al., 2020), and showing respect allowed them to form a strong connection, during a challenging time to engage, such as labour. In a study including 15 child-bearing women, the importance of respect was reinforced—they experienced positive relationships with maternity nurses when they felt respected (Madula et al., 2018).

5.1.2 Recognizing midwives' attitudes and beliefs

“Attitudes” and ‘beliefs’ refer to modes feeling and thinking, which affect behaviour and, therefore, the ability to develop relationships (Bradfield et al., 2019a; Carlton et al., 2009). Three qualitative studies (Backstrom et al., 2016; Bradfield et al., 2019a, 2019b) reported that midwives' negative or positive feelings were important for their attitudes towards developing supportive relationships with women. Eight articles (Aschenbrenner et al., 2016; Backstrom et al., 2016; Bradfield et al., 2019a, 2019b; Carlton et al., 2009; Goodwin et al., 2018; McInnes et al., 2020; Menage et al., 2020) discussed facilitators or barriers influencing midwives' or maternity nurses' attitudes. These included motivation, personality, preference, experience and knowledge (McInnes et al., 2020).

Experience and knowledge can empower midwives to manage challenges while building supportive relationships. The more educated and/or experienced the midwives/maternity nurses, the more their relationships were (Aschenbrenner et al., 2016; Bradfield et al., 2019a; Carlton et al., 2009; Menage et al., 2020). Further, when a midwife′s and a woman′s personalities do not match, it could impede the supportive relationship (Backstrom et al., 2016; Bradfield et al., 2019a). However, neither study discussed how the personalities might be mismatched.

5.1.3 Developing partnerships

Partnerships were discussed in 10 studies. Carlton et al. (2009) found that partnerships could be achieved when women and maternity nurses shared power. Partnerships include elements such as shared decision-making (Bradfield, Hauck, Duggan, et al., 2019; Bradfield et al., 2019a, 2019b), mutual involvement (Shimizu & Mori, 2018) and healthcare professionals advocating for empowering the woman (Bradfield, Hauck, Duggan, et al., 2019; Bradfield et al., 2019a, 2019b; Davison et al., 2015; Shimizu & Mori, 2018). Empowering child-bearing women is considered essential in supportive relationships (Menage et al., 2020). It is thought to occur when the midwife provides guidance (Crowther & Smythe, 2016) and advocates for the woman (Bradfield, Hauck, Duggan, et al., 2019). However, there were few details about when to share decision-making and the relevant aspects of the care.

Two qualitative studies (Bradfield, Hauck, Duggan, et al., 2019; Davison et al., 2015) asserted that woman-centred care could enhance positive and supportive relationships with women, facilitate shared decision-making and improve their birth outcomes, enhancing women′s satisfaction with care and birthing experiences. Seven studies (Bradfield, Hauck, Duggan, et al., 2019; Bradfield et al., 2019a; Davison et al., 2015; Goodwin et al., 2018; McInnes et al., 2020; Menage et al., 2020; Shimizu & Mori, 2018) also reported that woman-centred care that was tailored to the woman′s preferences facilitated supportive relationships .

Other studies identified positive relationships between women and midwives when women, their family members and significant others were involved in care planning (Bradfield et al., 2019a, 2019b; Davison et al., 2015; Goodwin et al., 2018; Shimizu & Mori, 2018). Shimizu and Mori′s (2018) study was conducted in Japan with a small sample size (N = 98). Although all study participants assessed their relationships with maternity nurses positively, Shimizu and Mori stated that it might not have been positive for those who did not participate. Furthermore, the women′s responses remained positive even when the questions did not apply. Finally, two studies (Bradfield et al., 2019a; Goodwin et al., 2018) reported that some women refused to choose or build any relationships and preferred their own space.

5.1.4 Effective communication skills

Effective communication skills are fundamental in any relationship. Nine articles (Aschenbrenner et al., 2016; Backstrom et al., 2016; Bradfield, Hauck, Duggan, et al., 2019; Bradfield et al., 2019b; Carlton et al., 2009; Crowther & Smythe, 2016; Madula et al., 2018; Menage et al., 2020; Oscarsson & Stevenson-Ågren, 2020) identified communication as an enabling practice for developing supportive relationships with women. In one study, midwives (n = 31) described how they used basic communication skills, such as gaining rapport and providing verbal encouragement, to facilitate relationships development with women (Bradfield, Hauck, Duggan, et al., 2019). Further, Backstrom et al. (2016), Oscarsson and Stevenson-Ågren (2020) and Menage et al. (2020) found that active listening skills are essential to developing supportive relationships. However, Madula et al. (2018) reported that a lack of interpersonal skills in midwives and maternity nurses was a common communication barrier leading to the women feeling frustrated about their unmet needs.

5.2.1 Women′s health beliefs

Bradfield et al., 2019a described the need for cultural safety, and understanding of women′s cultural backgrounds in the practice of maternity care, which requires trust and respect for other cultures. Two studies found that women and midwives valued supportive relationships, highlighting the importance of keeping this relationship non-judgmental to facilitate its building, especially in women and midwives with different cultural beliefs (Goodwin et al., 2018; Oscarsson & Stevenson-Ågren, 2020). Oscarsson and Stevenson-Ågren (2020) reported that women′s health beliefs affected their child-bearing practices, especially when they differed from midwives′ beliefs, all midwives in Oscarsson and Stevenson-Ågren′s study were Swedish, which may have affected the results because cultural diversity can affect midwives′ perceptions and experiences. The study also did not report the cultural beliefs of immigrant women, although they were not homogenous. Furthermore, one study in the UK (Goodwin et al., 2018) claimed that midwives tended to negatively judge Pakistani women when they were unaware of their cultural practices and beliefs, such as shaving a newborn′s head. Unfamiliarity with women′s beliefs, priorities and expectations was a barrier to developing supportive relationships (Goodwin et al., 2018).

5.2.2 Family involvement

Goodwin et al. (2018) reported that family dynamics in some cultures (e.g., Pakistani) significantly influenced the relationships between maternity nurses and women. Maternity nurses and midwives explained that family members influenced some women′s decisions and the dominant family member was often the decision-maker (Carlton et al., 2009; Goodwin et al., 2018; Oscarsson & Stevenson-Ågren, 2020). Extra attention to cultural influence on building supportive relationships was considered as a facilitator (Goodwin et al., 2018). Conversely, one study described how some women preferred to handle the labour and birth alone and not involve their partners, preferring to handle the labour and birth alone (Bradfield, Hauck, Duggan, et al., 2019).

5.3.1 Continuity of care

Eight studies reported that (COC) facilitates developing supportive relationships with women. Healthcare model differ between countries, influencing the type and extent of COC the maternity team provides. This review included different healthcare systems in which the studies were conducted. Some studies mentioned COC in the health systems in the UK (McInnes et al., 2020; Menage et al., 2020), Australia (Bradfield, Hauck, Duggan, et al., 2019; Bradfield et al., 2019a; Davison et al., 2015), Sweden (Backstrom et al., 2016; Oscarsson & Stevenson-Ågren, 2020), and NZ (Crowther & Smythe, 2016). Other studies have reported non-COC in systems, in the United State of America (Carlton et al., 2009) and Australia (Bradfield et al., 2019b).

Women and midwives in three qualitative studies (Backstrom et al., 2016; Bradfield et al., 2019b; McInnes et al., 2020) reported that COC in maternity services facilitates supportive relationships and trust. Additionally, Oscarsson and Stevenson-Ågren (2020) and Menage et al. (2020) suggested that midwives who cared for the same women throughout their pregnancies were more likely to build trusting relationships. However, midwives working in a birthing unit where COC was not practised expressed a feeling of disconnection with women (Bradfield et al., 2019b). Women in one study (Davison et al., 2015) wanted COC and preferred private midwifery care because the relationship with their midwives was as supportive as they needed and they could be involved in shared decisions. This study was conducted in one location in Australia (from 2007–2013) when support for publicly funded home birth was still being developed.

5.3.2 Time and workload

The literature highlighted several work situations as barriers to supportive relationships with child-bearing women; including lack of adequate time (Aschenbrenner et al., 2016; Bradfield, Hauck, Duggan, et al., 2019; Bradfield et al., 2019b; Carlton et al., 2009; Madula et al., 2018), heavy workloads (Aschenbrenner et al., 2016; Bradfield et al., 2019b; Carlton et al., 2009; Menage et al., 2020), and staff shortages (Aschenbrenner et al., 2016; Carlton et al., 2009). Maternity nurses felt distracted by paperwork and technological interventions, such as electronic fetal monitoring and high-risk protocols for all admitted women (Carlton et al., 2009). Carlton et al. (2009), Bradfield et al., 2019b and Crowther and Smythe (2016) found that midwives felt overloaded and often had to deal with staff shortages, which affected their abilities to provide care and develop relationships. Maternity nurses also reported a lack of time for developing supportive relationships with women due to their working conditions (Aschenbrenner et al., 2016; Carlton et al., 2009). Maternity nurses were challenged when they had to balance keeping electronic health records (EHRs) and women′s needs, such as electronic fetal monitoring (a part of HER), resulting in decreased time for building relationships (Aschenbrenner et al., 2016; Menage et al., 2020).

5.3.3 Physical environment

This sub-theme refers to organizational facilitators and barriers to providing resources and support for midwives to develop supportive relationships, which midwives considered a significant challenge to staying connected with women (McInnes et al., 2020). For example, birthing unit design can influence how women feel. Birthing room environments have varying levels of privacy, lighting, music or silence and hygiene facilities (Bradfield, Hauck, Duggan, et al., 2019). When the design matches a woman′s preferences, promotes a positive relationship between the woman and the midwife (Bradfield, Hauck, Duggan, et al., 2019; Menage et al., 2020). This can improve women′s physical and psychological comfort, enabling supportive relationships and positively affecting women′s feelings (Aschenbrenner et al., 2016; Bradfield, Hauck, Duggan, et al., 2019; Carlton et al., 2009; Menage et al., 2020).

6.1.1 Human interaction

Developing supportive relationships with child-bearing women requires mutual trust, respect, partnerships and attitudes and effective communication skills, all of which are interrelated and facilitate relationships. Partnerships allow women to feel empowered to share decision-making and make their own choices. They require provisions for involvement and advocacy (Bradfield, Hauck, Duggan, et al., 2019; Shimizu & Mori, 2018). Although some studies (Bradfield, Hauck, Duggan, et al., 2019; Bradfield et al., 2019a, 2019b; Davison et al., 2015; McInnes et al., 2020; Shimizu & Mori, 2018) identified involvement as a part of partnerships with child-bearing women, there is insufficient information regarding the process for encouraging such involvement. Some studies focused on partnership as a maternity care approach, a foundational premise in developing supportive relationships (Bradfield et al., 2019a, 2019b; Carlton et al., 2009). However, these studies did not demonstrate the steps necessary to build partnerships with women and thus, facilitate relationships. This area requires further research.

Appropriate shared decision-making and women′s involvement were not always present in the reviewed studies (Bradfield et al., 2019a, 2019b; Davison et al., 2015; Shimizu & Mori, 2018). Thus, there was little information about decision-making processes, including how, when and the degree to which women were involved in decision-making, which could be considered a barrier to building supportive relationships. Additionally, there was a lack of information about women′s understanding of empowerment, which may indicate their readiness to make their own decisions. While midwives should employ a woman-centred care approach, empowering women to participate in joint decision-making (Nursing and Midwifery Board of Australia, 2018), further research should clarify women′s understanding of empowerment.

Two studies reported described how midwives' or maternity nurses' attitudes, including their personalities, knowledge and experience, affected how they valued developing supportive relationships with women during childbirth (Bradfield et al., 2019a; Carlton et al., 2009). Midwives need to gain women′s trust through positive attitudes and respect for their individual needs and culture.

These human interaction factors will have little success without effective communication skills, which are the basis of relationship development (Aschenbrenner et al., 2016; Backstrom et al., 2016; Bradfield, Hauck, Duggan, et al., 2019; Bradfield et al., 2019b; Carlton et al., 2009; Crowther & Smythe, 2016; Madula et al., 2018; Menage et al., 2020; Oscarsson & Stevenson-Ågren, 2020). Positive communication between healthcare professionals and women facilitates trust, respect and support (Backstrom et al., 2016). Therapeutic communication should be supported and practised more often to meet women′s needs and facilitate relationship development (Fenton & Jones, 2015; World Health Organization, 2019).

6.1.2 Culture

The reviewed studies suggested some cultural factors, such as women′s health beliefs (Carlton et al., 2009; Goodwin et al., 2018), and family involvement (Oscarsson & Stevenson-Ågren, 2020) that might inhibit the effective communication needed to support the connection between women and midwives. For example, some studies found women had a different view from that of midwives—while midwives often viewed the control of family members as a negatively dominant influence, some women viewed that as a kind of support (Goodwin et al., 2018). Such a situation requires that midwives understand cultural influences to maintain supportive relationships in a preferred way.

Further, women from different cultures might present with varying health demands (Tehsin et al., 2018), and the cultural barriers can affect supportive relationships. Understanding women′s beliefs and culture can help midwives understand the reasons behind health practices, promote acceptance and facilitate supportive relationships. Therefore, assessing women′s expectations of maternity care can benefit relationship development.

However, the relevant literature included of 14 articles published over the last 10 years, from seven countries, with primarily Western cultures. Few studies focused on cultural factors that affect how supportive relationships develop, indicating a substantial gap in the literature. Country-specific studies are needed to explore cultural differences, views, expectations and health practices relevant to building relationships with child-bearing women.

6.1.3 Organization

This review indicates that COC is crucial to meeting women′s. Findings demonstrated that women and midwives prefer to know each other before child birth, preferably meeting during the antenatal period (Bradfield et al., 2019a), so their care can be continuous throughout the child-bearing period (McInnes et al., 2020). The familiarity between women and midwives has helped midwives understand women′s needs and identify changes in health statuses throughout their visits. Simultaneously, it has helped women feel more comfortable with their midwives and develop trusting and positive relationships (McInnes et al., 2020). This finding was supported by recent Cochrane reviews, which established COC as the gold standard for midwifery care and suggested it should be practised much more widely (Homer et al., 2019; Sandall et al., 2016). However, further studies should address how supportive relationships are enabled within maternity care environments with a non-COC model.

Findings have shown that midwives and maternity nurses are distracted by workloads due to documentation and technology interventions (Aschenbrenner et al., 2016). Developing a successful relationship requires a balance between all support aspects. Therefore, midwives desire enough time to build trust, respect and partnerships with women, particularly those from different cultures. They need extra time before, during and after meeting women to manage their increased workload (Kerr et al., 2014). One strategy for managing this challenge is more efficient documentation methods that enable more time and effort strengthening relationships with women (Kent & Morrow, 2014). Although the EHR might prompt workflows, several issues have been noted, such as ineffective time management and unexpected deficiencies in patient care and work flow (Abbey et al., 2012; Baumann et al., 2018). Thus, the effect of EHR on midwives' time needs more attention, suggesting staff training and EHR system modifications to increase the time available for women′s care (Coleman et al., 2021; Karp et al., 2019).