Chapter 34 The choice agenda and place of birth and care

An explicit choice agenda has been evident in Government maternity services policy since the landmark document Changing childbirth (DH 1993). This is also an integral theme in the subsequent documents The national service framework for children, young people and the maternity services (DH 2004) and Making it better: for mother and baby (DH 2007a). In the policy document Maternity matters it is stated that:

While midwives aim to give women choices and women are encouraged to make them, the concept of choice is not straightforward, particularly around the choice of place of birth. Choices are relative and are not solely made by what is on offer in any specific place or at any particular time; choices are influenced by the values and beliefs of women, midwives and doctors (Edwards 2005). The concept of choice also needs to be viewed against a backdrop of consumerism, information giving, risk, litigation and maternity services resources. An offer of choice must be matched with having the capacity to provide that choice. This applies to the choice of a hospital birth with availability of epidural anaesthesia or water birth, a freestanding birth centre or birth at home.

Some aspects of maternity care are often not actively chosen by women; antenatal ultrasound scanning and screening for fetal abnormalities have become so commonplace and ‘normalized’ that they are often perceived as part of a package of care and are rarely contested. Paradoxically, women may be perceived as more ‘difficult’ or ‘demanding’ if they choose not to have something rather than making a choice from a list of options given to them. It is self-evident that women need to be informed in order to make choices, but decisions around pregnancy, place of birth, labour, infant feeding and motherhood are shaped by a range of factors, many of which are influential before women even become pregnant. In the UK, hospital birth is the norm, reinforced by the processes of socialization, cultural imagery around labour and birth, and the language of safety and risk; therefore choices are set within this context.

In the context of choice and place of birth, Knightly (2007) comments that people are overloaded with information, especially from the media. In a sophisticated media age characterized by the swiftness of sound bites, it is difficult to get messages across based on ‘evidence’. The increasing evidence and government support of the suitability of birth at home or in midwife-led units needs to be matched with the messages conveyed in the media. The overriding notion that hospital birth is safe is supported by portrayals in popular culture of home birth as risky and fraught with danger.

Information giving by midwives and doctors is not a neutral activity; information is often framed in such a way as to maintain organizational and cultural norms and to encourage women to make certain approved or ‘right’ choices. This control by midwives has been referred to as ‘professional dominance’ (Stapleton et al 2002a), ‘strategic communication’ (Hindley & Thomson 2005) and ‘protective steering’ (Levy 2004).

In their study on the use of evidence-based leaflets on informed choice (MIDIRS Informed Choice leaflets), Stapleton et al (2002b) found that a minority of women were satisfied with the way information was presented. However, this mode of information giving, combined with few opportunities to discuss the leaflets, did not promote informed choice and active decision-making. Women generally complied with the ‘professionally defined right choices’ (Stapleton et al 2002b). Although the midwives in this study were positive about the leaflets, they exercised power in deciding to whom they would offer the leaflets, based on their perceptions of how realistic the choices were or whether women would understand or use them. Stapleton et al (2002b) argued that midwives are influenced by the cultural norms of their working environment, particularly power hierarchies, the use of technological interventions and the fear of litigation. They concluded that, ‘the culture into which the leaflets were introduced supported existing normative patterns of care and this ensured informed compliance rather than informed choice’ (Stapleton et al 2002b:639).

Information giving is not just about the transmission of objective ‘facts’ or even ‘evidence’; it is also about a dialogue concerning what is actually going on, particularly when things change during pregnancy, labour and birth. It is about relationships, communication and trust that involves active engagement with women in decision making (Leap & Edwards 2006, Pairman 2006, Rosser 2003). Enhancing these factors presents a challenge to the dominant culture of fear, litigation and defensive practice, and where they are lacking, dissatisfaction is greater (Symon 2002).

Clearly, ‘choice’ is the touchstone of the maternity services and NHS Trusts and midwives are exhorted to provide more choices, including where women can give birth to their babies (DH 2004, NICE 2007). For some women the most appropriate place for their needs will be consultant-led care within a hospital, but not all women. Yet, in the UK, 96% of women have their babies in hospital, with the remainder born either in midwifery-led units (either attached to a consultant unit or ‘freestanding’), birth centres or at home, with some regional differences (Birthchoice UK 2008). The Healthcare Commission report Towards better birth, a review of maternity services in England reported that around half of the women surveyed were offered a choice of where to have their baby and that up to a third of women would have liked more information around place of birth (Healthcare Commission 2008).

Arguments about risk and place of birth are usually constructed around medical/obstetric risk and issues of safety; social and physiological factors are rarely considered, particularly where an out-of-hospital birth may be appropriate for many women. Discussions around suitability for home birth or midwifery-led care away from consultant units are often framed around exclusion rather than inclusion criteria; why, for example, a woman should not have a home birth, rather than why she should have one. This approach reinforces hospital birth as the benchmark for the usual place of birth and this tradition of hospital birth has led to the institutionalization of birth in the UK (Leap & Edwards 2006). While there has been a rise in the number of midwifery-led units or birth centres, these remain small in number and are periodically closed or under threat of closure, primarily due to financial constraints, particularly shortages of midwives. The challenge for midwives is to balance the positive and persuasive arguments of ‘normality’ and ‘small is beautiful’ (Downe 2008, Kirkham 2003, Walsh 2007) with the current political climate of ‘risk’, reorganization, ‘rationalization’ and centralization of maternity services within the NHS.

Some authors urge caution against the polarization of home versus hospital in debates about the place of birth (Knightly 2007, Leap & Edwards 2006). What really matters is how maternity services can be organized to meet the needs of women; how a variety of services can be sustained within financial constraints; and how midwives can provide appropriate care as well as gaining personal and professional satisfaction and a work–life balance. For women, Leap and Edwards (2006) conclude:

For some women who have pre-existing medical or psychiatric conditions or develop complications during pregnancy and labour, consultant-led care and hospital birth are appropriate; this point has been clearly stated in the document Saving mothers’ lives: reviewing maternal deaths to make motherhood safer 2003–2005 (Lewis 2007). The majority of women do not usually require that type of care. Women who do not require expert obstetric interventions may have less favourable outcomes by being in a consultant-led unit that is often characterized by interventions to control labour and bring it to a ‘timely’ end. This can result in a ‘cascade of intervention’, a term first coined by Sally Inch (1990).

Although the NICE (2007) guidelines recommend offering low-risk mothers the choice of where they plan to have their babies, the guideline development group claim that they were ‘unable to determine whether planning birth in a non-obstetric setting is as safe as birth in an obstetric unit’ (NCC-WCH 2007). The National Childbirth Trust dispute this statement in their own review of the same papers on home birth (Gyte & Dodwell 2007). However, Gyte and Dodwell (2007) did not find evidence to suggest that hospital birth is any safer than home birth for low-risk women, echoing the conclusions of previous studies (Chamberlain et al 1997, Olsen & Jewell 1998). Further research into outcomes of planned births at home, in midwifery-led units or in hospital is being conducted by the National Perinatal Epidemiology Unit, Oxford, in their Birthplace in England research programme. This will report at a later date on ‘wellbeing, safety and quality, women’s experience of care, the process of transfer from planned place of birth, and the cost-effectiveness of different systems for care’ (NPEU 2008).

A significant challenge to the prevailing dominant cultural and social practice of hospital being the most appropriate place for birth is the birth centre. Birth centres may be either low-risk maternity units attached to hospitals with access to obstetric consultants or geographically separate from the hospital, often referred to as freestanding birth centres. However, the term ‘birth centre’ is generally considered to refer to more than just a building or a physically attractive space. It is about a social model of midwifery care that supports a philosophy that considers that a woman has the ability to give birth to and nurture her baby, at her own pace and without intervention, supported by skilled and sensitive midwives (Kirkham 2003, Walsh 2007). The philosophy clearly places the individual characteristics of the midwife as central to the successful working of a birth centre. This, together with clear policies on when medical opinion needs to be sought, should ensure that the birth centre maintains its focus on normality rather than becoming a satellite of the consultant-led unit.

For stand-alone units, the confidence and expertise of the midwives in dealing with both normal births and the rare but potential emergencies are paramount. Admission criteria for stand-alone birth centres are similar to those used for home birth. Birth centres pride themselves on providing a ‘home from home’ environment and rarely have any more equipment than community midwives carry in their cars. It is interesting that women appear to be more prepared to deliver in a birth centre than in their own homes; nationally, 16% have their babies in birth centres compared with a 2% homebirth rate (Bainbridge 2006). Birth centre studies demonstrate potential savings to the NHS in lower uses of resources associated with intrapartum care (Ratcliffe 2003) and positive health and social outcomes (Kirkham 2003). It may be that women perceive birth centres to be more appropriate or safer than home. It is possible that culturally, women expect to give birth in an institution and birth centres are perceived as a ‘halfway house’ between hospital birth and home birth. Yet Barber et al (2007) found that most women gave birth in hospital. In their BirthPlace Choices project on the south coast of England, Barber et al (2007) investigated the influence of providing women with information and introducing educational strategies around the place of birth. They found that the women in the survey said that, given the choice, they would opt for out-of-hospital births, yet the majority still gave birth in the hospital labour ward.

While the choice of birth ‘at home supported by a midwife’ (DH 2007a) is an option for women, the numbers of women giving birth at home have been persistently low throughout the UK over the past few decades, although these range from 0.0% to 10% dependent on location (Birthchoice UK 2008). Edwards (2005) considers that home birth, while supported by government and local policies, remains a contested area. One of the critical reasons for women choosing and midwives supporting home birth is that women can exercise more control over the birth process. It may be the alterations that occur in the balance of power, when a midwife becomes a visitor within the woman’s own home, which helps to promote this empowerment. In common with birth centre practice, successful outcomes are influenced by both the attitudes and skills of the attending midwife, who needs to be equally confident in the woman’s ability to give birth to her own baby as in her own skills to be more directive and make referrals should this becomes necessary.

Further evidence of the importance of this partnership comes from some Dutch research. The Netherlands have a much higher homebirth rate than the UK; women book with a midwife who then supports them through the labour either at home or in the hospital. Van der Hulst (1999) found an increase in relational care between the midwife and the mother during home births in comparison to hospital births. Midwives spent more time with and were more attentive to labouring women within the home environment. Home birth undertaken by midwives who do not feel comfortable doing so may equate to a ‘hospital birth’ undertaken at home. For some women, the choice of home birth is as much about the people she wants with her during her labour as the place of birth.

In most areas, the decision on where to give birth is often expected to be made at the initial antenatal (booking) visit. This may discourage a woman from fully considering her range of options as her pregnancy progresses or in light of further information from other women or midwives. However, midwives in the Albany Midwifery Practice, an NHS midwifery group practice in South East London, undertook home labour assessments and the decision on where the woman wants to give birth is made at that point (Reed 2002). A midwife known to the woman would remain with her and support her to give birth at home, unless the woman chose to go to hospital or the midwife and the woman consider it appropriate so to do.

Transfer to hospital for women who have originally planned a home birth is often constructed as a ‘failed home birth’. The use of such terminology not only is demeaning to the woman but also ignores the role of the midwife in providing continuity of care regardless of the actual place of birth. The example set by the Albany midwives, and other caseload or group practices, demonstrates the benefits and flexibility of following the mother to wherever is the appropriate place for her to have her baby – the birth is a success in itself; an ‘everyday miracle’ (Reed 2002:263).

Choices for women are enhanced through continuity of care schemes where women can develop meaningful relationships with midwives over a period of time (Gamble et al 2007, Page 1995, Sandall et al 2001). Caroline Flint’s pioneering ‘Know your midwife’ scheme in the mid 1980s (Flint et al 1989) was a catalyst for further change in the organization of midwifery care throughout the 1990s when schemes were developed around the concept of continuity of carer and ‘knowing your midwife’. Those midwives who work in a caseload team approach rather than a reciprocal arrangement with another midwife argue that it is the shared philosophy and attitude of the team rather than ‘knowing’ the individual midwife that influences the relationship (Edwards 2005).

Reflecting on the significance of the concept of continuity, Lee (1997) suggested that the concept is not clear and has a range of meanings, not least to women who receive care from midwives. Furthermore, there is little consensus regarding the term ‘named midwife’ and the meanings of ‘care’, ‘carer’, ‘team’, ‘caseload’ and women ‘knowing’ a midwife. In conclusion, Lee (1997) suggests that what women want is good care and that midwives should organize care in ways that increase the power of women, particularly the most vulnerable.

The caseload model is frequently used by independent self-employed midwives, working outside of the NHS in a private financial agreement with the expectant mother. Women receive one-to-one care from a known midwife. The situation for independent midwives changed after 2002, when the last commercial insurance product was withdrawn from the market. Thus, most independent midwives practise without professional indemnity insurance, thus posing a potential discouragement to prospective clients (Independent Midwives Association 2008). The threat to independent midwifery raises significant issues around the professional autonomy of midwives and the choices available to women (Anderson 2007).

In summary, women’s decisions about where to give birth are probably not based on objective statistical risk but rather on women’s own understandings of that risk. They are influenced by a range of social and cultural factors, alongside the ways in which midwives present information about the place of birth. Ideally, midwifery care will follow the woman regardless of whether she needs or wants to give birth in hospital, at home or in a birth centre. Increasingly, midwives should encourage women to see birth out of hospital as a safe choice for uncomplicated childbirth. Final decisions about the place of birth can be left for the woman to make during labour, thereby ensuring that she keeps all her options open. This means that midwives may move more freely between hospitals and the community.