Kirstie Coxon

To what extent are women free to choose where to give birth? How discourses of risk, blame and responsibility influence birth place decisions.

Over the past 50 years, two things have changed for women giving birth in high-income nations; birth has become much safer, and now takes place in hospital rather than at home. The extent to which these phenomena are related is a source of ongoing debate, but concern about high intervention rates in hospitals, and financial pressures on health care systems, have led governments, clinicians and groups representing women to support a return to birth in ‘alternative’ settings such as midwife-led birth centres or at home, particularly for well women with healthy pregnancies. Despite this, most women still plan to give birth in high-technology hospital labour wards. In this article, we draw on a longitudinal narrative study of pregnant women at three maternity services in England between October 2009 and November 2010. Our findings indicate that for many women, hospital birth with access to medical care remained the default option. When women planned hospital birth, they often conceptualised birth as medically risky, and did not raise concerns about overuse of birth interventions; instead, these were considered an essential form of rescue from the uncertainties of birth. Those who planned birth in alternative settings also emphasised their intention, and obligation, to seek medical care if necessary. Using sociocultural theories of risk to focus our analysis, we argue that planning place of birth is mediated by cultural and historical associations between birth and safety, and further influenced by prominent contemporary narratives of risk, blame and the responsibility. We conclude that even with high-level support for ‘alternative’ settings for birth, these discourses constrain women’s decisions, and effectively limit opportunities for planning birth in settings other than hospital labour wards. Our contention is that a combination of cultural and social factors helps explain the continued high uptake of hospital obstetric unit birth, and that for this to change, birth in alternative settings would need to be positioned as a culturally normative and acceptable practice.

Uncertainty in everyday life: Risk, worry and trust

This editorial provides an introduction to and overview of the six papers published in this special issue on Uncertainty and Risk in Everyday Life. While uncertainty and risk are connected and the terms often used interchangeably, we argue here that the terms are not synonymous. ‘Risk’ can be used both to describe the threat posed by uncertainty and the response to such threats. The approach to risk grounded in cognitive rationality involves collecting and analysing knowledge and using it as part of a formal decision-making process. Its development reflects the aspiration to control the world and its uncertainties through the use of systematic knowledge and is part of the increasing rationalisation of contemporary society. However, the investment of time and resources required means that this approach tends to be restricted to contexts in which such resources are available and the investments are considered worthwhile, i.e. they are most likely to be used by large scale bureaucratic organisations. By contrast, in everyday life the uncertainties are often fairly predictable and resources more limited. In such contexts, uncertainty tends to be viewed as worries or concerns that are often the product of the behaviour of other people. Individuals develop low cost strategies to manage their worries and concerns. These strategies draw on readily available resources: relationships, feelings and intuition which underpin both trust (through maintaining close relationships) and distrust (through avoiding threatening individuals and places).

Risk, pregnancy and childbirth: What do we currently know and what do we need to know? An editorial

In the first part of this editorial we reflect on some of the recent articles published in Health Risk & Society that contribute to our understanding of the ways in which the risks associated with pregnancy and childbirth are constructed. In the second part, we identify specific issues that would benefit from further study and which we would like to address in a forthcoming Health Risk & Society special issue.

Risk in pregnancy and birth: are we talking to ourselves?

In this editorial, I explore the contribution of the recent special issue of Health, Risk & Society (Volume 16, Issue 1), and three related papers published in the current volume (Volume 16, Issue 6), and identify themes and concepts which are consistent across these papers. The aims of the special issue were twofold; the call for papers invited articles on the topic of risk in relation to pregnancy and childbirth, and which sought to explore risk theorisation in this field. Looking at these papers as a body of work, I explore the breadth of this collective endeavour, and identify areas which have been researched at some depth, whilst drawing attention to other areas which manage to evade our theoretical gaze. I also reflect on the ways in which these papers have, independently and together, added to the field of risk theorisation, and propose some future directions which might usefully help move beyond the current limits of our enquiry. The combined body of work in these issues represents a considerable resource, and one which makes a clear contribution to contemporary understandings of risk, pregnancy and birth, however I argue that of late, the focus of enquiry has become narrowed, with much of our research providing new evidence from the perspective of relatively privileged women from high-income countries, who have good access to safe, high quality maternity care. The sum of this work is now such that it is possible to synthesise themes across studies and settings, which is valuable to our understanding, but the lack of research amongst women from developing nations, or amongst those with less privilege in high-income countries, means that our resource is incomplete, and fails to do justice to women’s broader experience of pregnancy and birth. Developments of risk theorisation are evident in the collected papers; authors have interrogated the positioning of individuals as subjects, and drawn new conclusions about historicised risk, and practices of resistance to risk discourse. I review these developments in this editorial, and also propose that the collection generates many new dimensions to our initial understanding of the ‘virtual object’ of risk in the context of pregnancy and birth. I conclude by outlining potential new directions and approaches to meet some of the identified gaps in our exploration and theorisation of risk in pregnancy and birth.

What influences birth place preferences, choices and decision-making amongst healthy women with straightforward pregnancies in the UK? A qualitative evidence synthesis using a ‘best fit’ framework approach

BackgroundEnglish maternity care policy has supported offering women choice of birth setting for over twenty years, but only 13% of women in England currently give birth in settings other than obstetric units (OUs). It is unclear why uptake of non-OU settings for birth remains relatively low. This paper presents a synthesis of qualitative evidence which explores influences on women’s experiences of birth place choice, preference and decision-making from the perspectives of women using maternity services.MethodsQualitative evidence synthesis of UK research published January 1992-March 2015, using a ‘best-fit’ framework approach. Searches were run in seven electronic data bases applying a comprehensive search strategy. Thematic framework analysis was used to synthesise extracted data from included studies.ResultsTwenty-four papers drawing on twenty studies met the inclusion criteria. The synthesis identified support for the key framework themes. Women’s experiences of choosing or deciding where to give birth were influenced by whether they received information about available options and about the right to choose, women’s preferences for different services and their attributes, previous birth experiences, views of family, friends and health care professionals and women’s beliefs about risk and safety. The synthesis additionally identified that women’s access to choice of place of birth during the antenatal period varied. Planning to give birth in OU was straightforward, but although women considering birth in a setting other than hospital OU were sometimes well-supported, they also encountered obstacles and described needing to ‘counter the negativity’ surrounding home birth or birth in midwife-led settings.ConclusionsOver the period covered by the review, it was straightforward for low risk women to opt for hospital birth in the UK. Accessing home birth was more complex and contested. The evidence on freestanding midwifery units (FMUs) is more limited, but suggests that women wanting to opt for an FMU birth experienced similar barriers. The extent to which women experienced similar problems accessing alongside midwifery units (AMUs) is unclear.Women’s preferences for different birth options, particularly for ‘hospital’ vs non-hospital settings, are shaped by their pre-existing values, beliefs and experience, and not all women are open to all birth settings.

How Do Pregnancy and Birth Experiences Influence Planned Place of Birth in Future Pregnancies?: Findings from a Longitudinal, Narrative Study

Abstract 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 womens 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 Womens 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 womens 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.

Interventions to support effective communication between maternity care staff and women in labour: A mixed-methods systematic review

Objectives the objectives of this review were (1) to assess whether interventions to support effective communication between maternity care staff and healthy women in labour with a term pregnancy could improve birth outcomes and experiences of care; and (2) to synthesize information related to the feasibility of implementation and resources required. Design a mixed-methods systematic review. Setting and participants studies which reported on interventions aimed at improving communication between maternity care staff and healthy women during normal labour and birth, with no apparent medical or obstetric complications, and their family members were included. ‘Maternity care staff’ included medical doctors (e.g. obstetricians, anaesthetists, physicians, family doctors, paediatricians), midwives, nurses and other skilled birth attendants providing labour, birth and immediate postnatal care. Studies from all birth settings (any country, any facility including home birth, any resource level) were included. Findings two papers met the inclusion criteria. One was a step wedge randomised controlled trial conducted in Syria, and the other a sub-analysis of a randomised controlled trial from the United Kingdom. Both studies aimed to assess effects of communication training for maternity care staff on womens experiences of labour care. The study from Syria reported that a communication skills training intervention for resident doctors was not associated with higher satisfaction reported by women. In the UK study, patient-actors’ (experienced midwives) perceptions of safety and communication significantly improved for postpartum haemorrhage scenarios after training with patient-actors in local hospitals, compared with training using manikins in simulation centres, but no differences were identified for other scenarios. Both studies had methodological limitations. Key conclusions and implications for practice the review identified a lack of evidence on impact of interventions to support effective communication between maternity care staff and healthy women during labour and birth. Very low quality evidence was found on effectiveness of communication training of maternity care staff. Robust studies which are able to identify characteristics of interventions to support effective communication in maternity care are urgently needed. Consideration also needs to be given to how organisations prepare, monitor and sustain interventions to support effective communication, which reflect outcomes of priority for women, local culture and context of labour and birth care.

Spousal violence and receipt of skilled maternity care during and after pregnancy in Nepal.

OBJECTIVES a substantial number of Nepali women experience spousal violence, which affects their health in many ways, including during and after pregnancy. This study aimed to examine associations between womens experiences of spousal violence and their receipt of skilled maternity care, using two indicators: (1) receiving skilled maternity care across a continuum from pregnancy to the early postnatal period and (2) receiving any skilled maternity care in pregnancy, childbirth, or postpartum. METHODS data were analysed for married women aged 15-49 from the 2011 Nepal Demographic and Health Survey. Data were included on women who completed an interview on spousal violence as part of the survey and had given birth within the five years preceding the survey (weighted n=1375). Logistic regression models were developed for analyses. RESULTS the proportion of women who received skilled maternity care across the pregnancy continuum and those who received any skilled maternity care was 24.1% and 53.7%, respectively. Logistic regression analyses showed that spousal violence was statistically significantly associated with receiving low levels of skilled maternity care, after adjusting for accessibility of health care. However, after controlling for womens sociodemographic backgrounds (age, number of children born, educational level, husbands education level, husbands occupation, region of residence, urban/rural residence, wealth index), these significant associations disappeared. Better-educated women, women whose husbands were professionals or skilled workers and women from well-off households were more likely to receive skilled maternity care either across the pregnancy continuum or at recommended points during or after pregnancy. CONCLUSION spousal violence and low uptake of skilled maternity care are deeply embedded in a society in which gender inequality prevails. Factors affecting the receipt of skilled maternity care are multidimensional; simply expanding geographical access to maternity services may not be sufficient to ensure that all women receive skilled maternity care.

PP21 Organisational Influences on Variation in Rates of Caesarean Section Among English NHS Trusts after Accounting for Maternal and Clinical Risk: A Cross-Sectional Study

Background The proportion of women in England having a caesarean has increased from 9% to 24.8% between 1980 and 2012. There is increasing attention focused on the short and long term effects on the mother and the baby and efforts to have an increased understanding of associated influences. Previous research has adjusted for population case-mix (Bragg al 2010), but there has been less research on the relative impact of organisational factors which is the aim of this study. Methods A retrospective cross-sectional analysis was performed using routinely collected data from Hospital Episode Statistics dataset with over 660,000 deliveries in 144 NHS trusts in England. The dataset included all women giving birth between April 2010 and March 2011. The outcome was whether the delivery was by caesarean section. Clinical risk factors were calculated using the NICE intrapartum guideline criteria for women at increased risk of complications at the end of pregnancy. Exploratory statistical analysis of caesarean rates for each trust was performed to identify significant variation in rates (both planned and emergency). A multilevel logistic regression model was used to estimate the likelihood of women having a caesarean section given their maternal (level 1) characteristics (age, ethnicity, parity, socioeconomic deprivation), clinical risk factors (NICE Intrapartum guideline criteria) and organisational (level 2) factors (staffing, trust configuration, number of delivery beds, number of deliveries, teaching and Foundation Trust status, CNST rating and women’s experience). Results In 2010/11, 48% of women in England were categorised as low risk according to NICE Intrapartum Guidelines at the end of pregnancy. Among 660,000 deliveries, 24.8% of women were delivered by caesarean section. Unadjusted rates of caesarean section among the NHS trusts ranged from 36.1% down to 15.2%. Following adjustment for socio-demographic and clinical risk factors, adjusted rates were of a similar range but rates for individual trusts changed, and the impact of organisational factors were examined. Discussion Once adjusted for socio-demographic and clinical risk factors, it is possible to see how caesarean rates for trusts differ. We discuss the relative impact of organisational characteristics, and what requires further exploration. Routinely collected data can provide information about the type of births that women are experiencing, and provide the means to adjust trust data to take account of the profile of women giving birth in each location, and organisational characteristics. This allows trusts to benchmark its services for quality improvement and provides baseline data for exploring reasons for high and low performing outliers.