Juliet Rayment presents some findings from the Birthplace in England Research Programme
There’s been a lot of talk in recent years about choice in health services. Back in 2004, the White Paper, ‘Choosing Health: Making healthy choices easier’1 suggested that we might all be able to choose to be healthy. ‘Maternity Matters: Choice, access, continuity of care in a safe service’2 put women’s choice of where they could give birth top of its agenda. The current NHS reforms have been justified to us on a promise that they will increase patient choice and that increasing choice is an indisputably good thing. However, ‘choice’ is not as straightforward as it might seem.
This article presents some findings from four case studies of English NHS Trusts: Seaview NHS Foundation Trust, City NHS Foundation Trust, Hillside NHS Trust and Shire NHS Trust (all names are pseudonyms) carried out as part of the Birthplace in England Research Programme.3, 4 The Case Studies examined the maternity services of four ‘best performing’ English Trusts (according to the Health Care Commission Review of Maternity Services in England, 2007). Seventy two interviews were carried out with service users and their partners and another eighty-six with staff and local stakeholders at the four Trusts. Fifty observation visits were also made to the Trusts during 2010.
Speaking to women and their partners, to healthcare professionals and commissioners in these four case study sites exposed how women’s choices are frequently both constrained and unequal. In order to make a choice, women required information, access to local services and to feel safe.
Making choices requires information about opportunities available and there was evidence that even within a local area, women were being given differing advice and information. When obstetric units were the default option for most women, access to information about alternatives was crucial for women to be able to choose out of hospital birth.
One woman in Seaview described the importance of getting good information about her options:
‘I have to say at the beginning I never, ever thought of having a home birth. It wasn’t even on my … it wasn’t even on my radar. In fact I think one of my friends had had one a few years before and I thought she was barking, absolutely barking mad. But I didn’t have all the information, in terms of, you know that people could have home births and that, you know, if everything was straightforward in your pregnancy then there’s no reason why you can’t, basically, which was a message which we were given. (…) if you’ve got your information then a woman can make a choice accordingly really.’
Postnatal woman 1, Seaview
Even in the same area, professionals appeared to tailor information according to their assumptions about what women wanted or what would be most suitable for them:
‘I think she probably assumed that it would be hospital so she just circled that bit on the front of the notes, and that was about it. Until we starting talking about it at the antenatal classes and then I brought it up at one the meetings with the, the midwife. But that was quite late on. (…) I just said that I’d been considering a home birth… and they were really positive about that, they thought that was a really good idea, which I was quite surprised, I thought it would’ve more sort of… “oh we prefer hospital.”‘
Postnatal woman 2, Seaview
Choice of place of birth relied upon there being local services available. Particularly in rural areas, women’s choices were limited simply because they had no local out of hospital birth places available to them:
‘[The Freestanding midwife-led unit is] just a bit far…I don’t think I’d have handled an hour’s journey, [laughs] I’d be on the roof! And as well I’ve got all, like my mum lives round the corner so as soon as I had the baby she came in. So it made it better.’
Postnatal woman, Hillside
By offering a number of freestanding midwife-led units, Shire, a rural trust, was able to offer more realistic choices to women. Their units were successful because they were not just a midwifery concern:
‘The local geography makes it difficult for people to get to the OU out of hours so the local units are crucial.’
Obstetrician 1, Shire
‘It’s a quality service. I think when you run clinics in the peripheral hospitals and you realise how much quality they provide, quality service they provide, and, you know, for the women it’s just a lovely environment to give birth.’
Obstetrician 2, Shire
Most of the women and partners we spoke to had chosen to birth in an obstetric unit. This reflects the findings of the Birthplace cohort study that only 8% of 'low-risk' women in England plan to give birth in midwife led units or at home.
Many women chose an obstetric unit because they were concerned about the risk to them and their babies of birthing elsewhere and women described making complex personal risk assessments when choosing to birth out of hospital. The obstetric unit was understood as a place that was assumed to be safe, with the other birth places then progressively ‘less safe’ the more different they were from that institutional hub: first alongside midwife-led units, then freestanding midwife-led units, then birth at home. Different birth places were believed to be safer than others, not simply because they were geographically closer to the obstetric unit, but because they were closer to the medical model.
The birthplace cohort study found that a significant number of women (between 21 and 26.4%) were transferred into obstetric units during or shortly after labour. Worries about transferring during labour were a key reason women chose to birth in an obstetric unit and these concerns were shared by women who lived close to the hospital, as well as those who lived further away:
‘I definitely didn’t want to have the baby at home, I just thought if anything goes wrong and you’re at home it’s like… although I only live like 15 minutes, 10 minutes away, it’s still the thought that when you’re in hospital you’ve got all that help at hand, right there.’
Postnatal woman, Hillside
While transfer, or escalation of care within the obstetric unit, could be distressing and frightening, it was not inevitably a negative experience. Careful explanation of events by professionals had a positive effect on women and partners’ experiences, as this woman in Shire explained:
‘They were calm and knew exactly what they were doing, explained a bit about what it was they needed to do but weren’t going into the absolute nth degree, because you’re not in a position to take in loads and loads of information.’
Postnatal woman, Shire
Women felt safer when they were listened to and when staff acted on their concerns, even when complications developed during labour. Partners and other supportive companions helped to ensure that women who were worried about their own health were heard and taken seriously and this had a profound effect on their feelings about their birth:
‘After they gave me the epidural and they pressed the crash button (...) so many people were sticking needles inside of me and I was really scared and no one could explain to me what was going on. My sister had to tell them all to stop that, let them basically explain to me cause I was telling them noone should touch me cause I didn’t know what was going, because I was really scared and I was like what is going on with the baby and what is going on with me cause by that time I was so numb from basically from my neck all the way down and I didn’t know what was going on.’
Postnatal woman, City
The Birthplace cohort study showed that the incidence of birth interventions in fact decreased the further women planned to birth from the obstetric unit. However, the case studies interviews demonstrated how important it is that we do not underestimate the value of women feeling safe in hospital, even if their risk of intervention is higher:
Woman: They ask me (…) maybe you want it at home or hospital, and I says, ‘of course hospital’ it’s…it’s…
Partner: More safe.
Woman: Yeah, more safe.
Interviewer: Can you explain that to me? Why should it be more safe?
Woman: Because in … at home, ok, it’s midwife, but don’t have this all apparatus … the apparatus.
Woman: Instrument, if something happened, of course it’s better in hospital because it’s a lot doctor, more midwife, more professional.
Partner: Yeah (…) and we mentally feel more safe.
Postnatal woman and partner, City
Supporting out of hospital birth
The Birthplace in England Cohort Study has given the best available evidence to date that women deemed to be ‘low-risk’ would benefit from planning to birth outside of the obstetric unit. However, as we live within a culture that normalises obstetric unit birth, how can midwives support out of hospital birth whilst respecting women’s need to feel safe?
The case studies can give us some ideas:
• Midwife-led units need support from community midwives, who initiate those first conversations with women about place of birth. Communication between midwives working in different parts of the services is important, as inequality in the way information is given to women means inequality in who uses those services.
• Successful midwife-led units are led by midwives who work well with their obstetric colleagues to ensure their support.
• Women benefit from clear information from health practitioners, and support from their birth partners and companions, especially when complications develop during labour.
• Normal birth can be supported within the obstetric unit when midwife-led units aren’t available because they don’t exist, are too far away to be a realistic choice, are closed or women do not want to use them.
The authors of the study
Juliet Rayment is a Sociologist and is a Research Associate in the School of Health Sciences, City University London.
Susanna Rance is a Sociologist and is a Research Associate in the Division of Women's Health, King's College London.
Christine McCourt is Professor of Maternal and Child Health at City University London.
Jane Sandall is Professor of Social Science and Women's Health at King's College London.
This project was funded by the NIHR Health Services and Delivery Research programme (project number 08/1604/140). The author's views and opinions in this article do not necesarily reflect those of the funders, the NHS or the Department of Health
1. Department of Health (2004) Choosing Health: Making healthy choices easier. London: HMSO.
2. Department of Health (2007) Maternity Matters: Choice, access, continuity of care in a safe service. London: HMSO.
3. McCourt, C, Rance, S, Rayment, J, Sandall, J (2011) Birthplace in England Research programme: Organisational Case Studies Final Report 6. London: DH/SDO.
4. Hollowell, J, Puddicombe, D, Rowe, R, Linsell, L, Hardy, P, Stewart, M et al. (2011) The birthplace national prospective cohort study: perinatal and maternal outcomes by planned place of birth. Birthplace in England research programme. Final report part 4: NIHR service delivery and organisation programme. Available at www.sdo.nihr.ac.uk/projdetails.php?ref=08-1604-140
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