The effect of a birthplace decision support tool on women’s decision-making and information gathering behaviours during pregnancy: mybirthplace study protocol

Background The Maternity Review for England highlighted the need for more accessible information to support decisions. This study assesses the effect of a decision support tool (DST) on women’s decision-making regarding birthplace. Methods A mixed method sequential exploratory design involving three phases and 169 women from a large UK maternity hospital. Phase one: A questionnaire survey pre and post-access to the DST examining knowledge level and stages of decision-making scale. Phase 2: Follow-up questionnaire at 28 weeks to enable the usefulness of Mybirthplace to be evaluated. Phase 3: Qualitative interviews with 10 purposely chosen women at 36 weeks gestation. Collection of data on actual birthplace. Discussion This study is the first to assess the effect of a DST in supporting women’s choice of place of birth

'She can't come here!' Ethics and the case of birth centre admission policy in the UK

Using ethnographic data lifted from an investigation into midwifery talk and practice in the South of England, this paper sets out to interrogate the ethics underpinning current admission policy for Free Standing (midwifery led) Birth Centres in the UK. The aim of this interrogation is to contest the grounds upon which birth centres admissions are managed, particularly the over-reliance on abstract calculations of risk—far removed from the material lived experience of the mother wishing to access these birth centre services

The economic costs of intrapartum care in Tower Hamlets: a comparison between the cost of birth in a freestanding midwifery unit and hospital for women at low risk of obstetric complications

Objective To compare the economic costs of intrapartum maternity care in an inner city area for ‘low risk’ women opting to give birth in a freestanding midwifery unit compared with those who chose birth in hospital. Design Micro-costing of health service resources used in the intrapartum care of mothers and their babies during the period between admission and discharge, data extracted from clinical notes Setting The Barkantine Birth Centre, a freestanding midwifery unit and the Royal London Hospital’s consultant-led obstetric unit, both run by the former Barts and the London NHS Trust in Tower Hamlets, a deprived inner city borough in east London, England, 2007-2010. Participants Maternity records of 333 women who were resident in Tower Hamlets and who satisfied the Trust’s eligibility criteria for using the Birth Centre. Of these, 167 women started their intrapartum care at the Birth Centre and 166 started care at the Royal London Hospital. Measurements and findings Women who planned their birth at the Birth Centre experienced continuous intrapartum midwifery care, higher rates of spontaneous vaginal delivery, greater use of a birth pool, lower rates of epidural use, higher rates of established breastfeeding and a longer post-natal stay, compared with those who planned for care in the hospital. The total average cost per mother-baby dyad for care where mothers started their intrapartum care at the Birth Centre was £1296.23, approximately £850 per patient less than the average cost per mother and baby who received all their care at the Royal London Hospital. These costs reflect intrapartum throughput using bottom up costing per patient, from admission to discharge, including transfer, but excluding occupancy rates and the related running costs of the units. Key conclusions and implications for practice The study showed that intrapartum throughput in the Birth Centre could be considered cost-minimising when compared to hospital. Modelling the financial viability of midwifery units at a local level is important because it can inform the appropriate provision of these services. This finding from this study contribute a local perspective and thus further weight to the evidence from the Birthplace Programme in support of freestanding midwifery unit care for women without obstetric complications

‘Keeping Birth Normal’: Exploratory evaluation of a training package for midwives in an inner-city, alongside midwifery unit

Objectives to gain understanding about how participants perceived the value and effectiveness of ‘Keeping Birth Normal’ training, barriers to implementing it in an along-side midwifery unit, and how the training might be enhanced in future iterations. Design exploratory interpretive. Setting inner-city maternity service. Participants 31 midwives attending a one-day training package on one of three occasions. Methods data were collected using semi-structured observation of the training, a short feedback form (23/31 participants), and focus groups (28/31 participants). Feedback form data were analysed using summative content analysis, following which all data sets were pooled and thematically analysed using a template agreed by the researchers. Findings We identified six themes contributing to the workshop's effectiveness as perceived by participants. Three related to the workshop design: (1) balanced content, (2) sharing stories and strategies and (3) ‘less is more.’ And three related to the workshop leaders: (4) inspiration and influence, (5) cultural safety and (6) managing expectations. Cultural focus on risk and low prioritisation of normal birth were identified as barriers to implementing evidence-based practice supporting normal birth. Building a community of practice and the role of consultant midwives were identified as potential opportunities. Key conclusions and implications for practice a review of evidence, local statistics and practical skills using active educational approaches was important to this training. Two factors not directly related to content appeared equally important: catalysing a community of practice and the perceived power of workshop leaders to influence organisational systems limiting the agency of individual midwives. Cyclic, interactive training involving consultant midwives, senior midwives and the multidisciplinary team may be recommended to be most effective

Organisational strategies and midwives' readiness to provide care for out of hospital births: An analysis from the Birthplace organisational case studies

Objective: the objective of the Birthplace in England Case Studies was to explore the organisational and professional issues that may impact on the quality and safety of labour and birth care in different birth settings: Home, Freestanding Midwifery Unit, Alongside Midwifery Unit or Obstetric Unit. This analysis examines the factors affecting the readiness of community midwives to provide women with choice of out of hospital birth, using the findings from the Birthplace in England Case Studies. Design: organisational ethnographic case studies, including interviews with professionals, key stakeholders, women and partners, observations of service processes and document review. Setting: a maximum variation sample of four maternity services in terms of configuration, region and population characteristics. All were selected from the Birthplace cohort study sample as services scoring ‘best’ or ‘better’ performing in the Health Care Commission survey of maternity services (HCC 2008). Participants: professionals and stakeholders (n=86), women (64), partners (6), plus 50 observations and 200 service documents. Findings: each service experienced challenges in providing an integrated service to support choice of place of birth. Deployment of community midwives was a particular concern. Community midwives and managers expressed lack of confidence in availability to cover home birth care in particular, with the exception of caseload midwifery and a ‘hub and spoke’ model of care. Community midwives and women's interviews indicated that many lacked home birth experience and confidence. Those in midwifery units expressed higher levels of support and confidence. Key conclusions and implications for practice: maternity services need to consider and develop models for provision of a more integrated model of staffing across hospital and community boundaries

Service configuration, unit characteristics and variation in intervention rates in a national sample of obstetric units in England: an exploratory analysis

Objectives: To explore whether service configuration and obstetric unit (OU) characteristics explain variation in OU intervention rates in "low-risk" women. Design: Ecological study using funnel plots to explore unit-level variations in adjusted intervention rates and simple linear regression, stratified by parity, to investigate possible associations between unit characteristics/configuration and adjusted intervention rates in planned OU births. Characteristics considered: OU size, presence of an alongside midwifery unit (AMU), proportion of births in the National Health Service (NHS) trust planned in midwifery units or at home and midwifery "under" staffing. Setting: 36 OUs in England. Participants: "Low-risk" women with a "term" pregnancy planning vaginal birth in a stratified, random sample of 36 OUs. Main outcome measures: Adjusted rates of intrapartum caesarean section, instrumental delivery and two composite measures capturing birth without intervention ("straightforward"and "normal" birth). Results: Funnel plots showed unexplained variation in adjusted intervention rates. In NHS trusts where proportionately more non-OU births were planned, adjusted intrapartum caesarean section rates in the planned OU births were significantly higher (nulliparous: R2=31.8%, coefficient=0.31, p=0.02; multiparous: R2=43.2%, coefficient=0.23, p=0.01), and for multiparous women, rates of "straightforward" (R2=26.3%, coefficient=-0.22, p=0.01) and "normal" birth (R2=17.5%, coefficient=0.24, p=0.01) were lower. The size of the OU (number of births), midwifery "under" staffing levels (the proportion of shifts where there were more women than midwives) and the presence of an AMU were associated with significant variation in some interventions. Conclusions: Trusts with greater provision of non-OU intrapartum care may have higher intervention rates in planned "low-risk" OU births, but at a trust level this is likely to be more than offset by lower intervention rates in planned non-OU births. Further research using high quality data on unit characteristics and outcomes in a larger sample of OUs and trusts is required

How do pregnancy and birth experiences influence planned place of birth in future pregnancies? Findings from a longitudinal, narrative study

BACKGROUND: A perception that first birth is more risky than subsequent births has led to women planning births in obstetric units (OU) and to care providers supporting these choices. This study explored the influence of pregnancy and birth experiences on women's intended place of birth in current and future pregnancies. METHODS: Prospective, longitudinal narrative interviews (n = 122) were conducted with 41 women in three English National Health Service sites. During postnatal interviews, women reflected on their recent births and discussed where they might plan to give birth in a future pregnancy. Longitudinal narrative analysis methods were used to explore these data. RESULTS: Women's experience of care in their eventual place of birth had more influence on decisions about the (hypothetical) next pregnancy than planned place of birth during pregnancy did. Women with complex pregnancies usually planned hospital (OU) births, but healthy women with straightforward pregnancies also chose an OU and would often plan the same for the future, particularly if they experienced giving birth in an OU setting during recent births. DISCUSSION: The experience of giving birth in a hospital OU reinforced women's perceptions that birth is risky and uncertain, and that hospital OUs are best equipped to keep women and babies safe. The assumption that women will opt for lower acuity settings for second or subsequent births was not supported by these data, which may mean that multiparous women who best fit criteria for non‐OU births are reluctant to plan births in these settings. This highlights the importance of providing balanced information about risks and benefits of different birth settings to all women during pregnancy