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A qualitative study of information about available options for childbirth venue and pregnant women’s preference for a place of delivery

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A qualitative study of information about available options for childbirth venue and pregnant women’s preference for a place of delivery

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To explore the level of information about possible venues for childbirth among pregnant women, and to establish the midwives' involvement in giving information and helping women to make choices about where they want to give birth. Qualitative study using tape-recorded unstructured interviews. The South East of England. 33 pregnant women; 20 planning a hospital birth and 13 planning a home birth recruited between 32 and 42 weeks of pregnancy. Women planning a home birth were well informed about the options available to them, while the majority of those planning a hospital birth were less informed about the availability of home birth and assumed that the hospital was the only option. Midwives did not initiate the discussion of availability of home birth but supported those who already knew and asked for it. Almost a decade after the adoption of Changing Childbirth (DoH 1993) recommendations as policy in England there is still evidence of lack of information among pregnant women regarding services available to them. In this study the midwives' reluctance to inform women about home birth as a possible venue for childbirth, has been demonstrated.
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A qualitative study of information
about available options for childbirth
venue and pregnant womens
preference for a place of delivery
BanyanaCeciliaMadiandRosemaryCrow
Aim: to explore the level of information about possible venues for childbirth among preg-
nant women, and to establish the midwives’ involvement in giving information and helping
women to make choices about where they want to give birth.
Design: qualitative study using tape -recorded unstructured interviews.
Setting: the South East of England.
Participants: 33 pregnant women; 20 planning a hospital birth and 13 planning
a home birth recruited between 32 and 4 2 weeks of pregnancy.
Findings: women planning a home birth were well informed about the options available to
them, while the majorityof those planning a hospital birth were less informed about the
availability of home birth and assumed that the hospital was the only option. Midwives did
not initiate the discussion of availability of home birth but supported those who already
knew and asked for it.
Conclusions: almost a decade after the adoption of Changing Childbirth (DoH 1993) recom-
mendations as policy in England there is still evidence of lack of information among preg-
nant women regarding services available to them.In this study the midwives’ reluctance
to inform women about home birth as a possible venue forchildbirth, has been demon-
strated. &2003 Elsevier Ltd. Allrightsreserved.
BACKGROUND
The publication of Changing Childbirth (Depart-
ment of Health (DoH) 1993), and the subsequent
adoption of its recommendations as policy in
England in 1994 brought some hope that real
choice and control would be in women’s hands
(Ralston 1994). Midwives were recommended as
better placed to take charge of the care of all
women with normal pregnancies (DoH 1993).
The policy document recommended that women
should be empowered by being given adequate
information about all services and choices
available to them to enable them to make
informed decisions about their care, including
the choice of where they want their babies to be
born. Prior to this policy document, it was very
difficult for women to have a home birth because
recommendations for a place of delivery fa-
voured institutional deliveries (Ministry of
Health 1959,Department of Health and Social
Security 1970,House of Commons Social
Services Committee 1980). The hospital was
considered the quintessence of safety in child-
birth for both mother and baby. The view that
the hospital was safer than the woman’s own
home for childbirth, and the policy of encoura-
ging all women to give birth in hospital became
the subject of debate as others disagreed on the
basis that the evidence did not support the
premise (Tew 1977, 1985, 1990,Russell 1982,
Campbell & Macfarlane 1987, 1994, Murphy &
Fullerton 1998).
A MORI poll commissioned to inform the
Changing Childbirth committee found that 72%
of the respondents were not given a choice about
ARTICLE IN PRESS
(Correspo ndence to BCM,
E-mail: bcm@socsci.soton.
ac.uk)
Received 3 July 2002
Revised15 October 2002;
30 April 2003
Accepted 20 May 2003
Banyana Cecilia Madi
PhD, MSc, RM, RGN
Wellcome Trus t
Postdo c toral F ellow,
Department of Social
Statistics,University of
Southampton, Highf|eld,
Southampton, SO171BJ,UK
Rosemary Crow
PhD, MA, RM, RGN
Professor of Nursing,
Universi ty of Surr ey, UK
Midwifery (2 003) 19, 328^33 6 &2003 El sevier Ltd. All rights re served.
doi:10.1016/S0266-6138(03)00042-1/midw.2003.0369
the place of delivery (Market Opinion Research
Institute (MORI) 1993). The House of Com-
mons Health Committee pointed to widespread
demand for choice, from women, about the type
of maternity care, and the concomitant frustra-
tion due to the lack of choice provided by the
maternity services (House of Commons Health
Committee 1992). Earlier studies have suggested
a desire for more information about childbirth,
and problems with getting adequate information
(Oakley 1979,Reid & Mcllwaine 1980,Jacoby
1988,Mander 1993, Kirkham 1999). Even more
important, subsequent studies still suggest a lack
of information about options for childbirth,
including the place of delivery (Mckay & Smith
1993,Gready et al. 1995,Davies et al. 1996,
Chamberlain et al. 1997,Garcia 1999,Hundley
et al. 2000,O’Cathain et al. 2002). A recent
survey using 1188 pregnant women found that
43% wanted more information about maternity
care choices (Singh et al. 2002). Another study
has suggested that only 5% of midwives routi-
nely offer home birth as an option at ‘booking’
(Floyd 1995).
Other countries of the UK have policies that
promote woman-centred care (Welsh Office
1991,Scottish Office 1993,Department of
Health and Social Services Northern Ireland
1994). However, The Royal College of Midwives
(RCM) has observed that since the introduction
of woman-centred care the home birth rate has
increased only slightly compared to the number
of women who would like the service (RCM
2002). The RCM reiterates that women have a
right to choose where to give birth, and that
helping women to make informed choices
and promoting home birth is good practice,
which is congruent with government policy
(RCM 2002).
Making real choices involves a process of
giving and sharing of information that would
assist in the decision making. Exercising choice
in childbirth would involve women first getting
information about the issues to be considered,
and the options available to them from their
midwives and/or other sources. However, in a
literature review of women’s views on their
maternity care in the UK (Dowswell et al.
2001) some of the reviewed studies suggested
that women did not perceive that they were
offered choice about their care (Gready et al.
1995,Davies et al. 1996, 1997,Chamberlain et al.
1997,Garcia 1999). There is a dearth of
descriptive literature on the specific topic of
women’s views about the information they are
given about available venues for childbirth, and
the midwives’ involvement in helping them make
choices about where to give birth. Most studies
on the subject have looked at general views
about preferences for home and hospital deliv-
eries using quantitative methods (Mather 1980,
Soderstrom et al. 1990,Cunningham 1993,
Waldenstrom & Nilsson 1993,Jones & Smith
1996,Davies et al. 1996,Fordham 1997,
Viisainen et al. 1998,Churchill & Benbow
2000,Hundley et al. 2000) while few used
qualitative methods (Kleiverda et al. 1990,
Mackey 1990,Coyle et al. 2001). The main
findings are that women choosing to have their
babies at home are hoping to have more
flexibility, choice and control during the birth
process (Kleiverda et al. 1990,Mackey 1990,
Soderstrom et al. 1990,Davies et al. 1996,
Fordham 1997). The other suggestion from the
studies is that women choosing a hospital birth
are concerned about safety (Mather 1980,
Mackey 1990,Soderstrom et al. 1990,Cunning-
ham 1993,Jones & Smith 1996,Chamberlain
et al. 1997).
The present study is part of a wider qualitative
study that examined women’s views about
factors affecting their preference for place of
delivery. The aim of the current study was to
elucidate how much information women have
about the availability of home and hospital as
childbirth venues, and how their midwives are
involved in helping them make their choice of
where to give birth.
METHODS
Design
A grounded theory approach (Glaser & Strauss
1967) was used to elicit pregnant women’s views
about their knowledge of possible venues avail-
able to them for childbirth, and to elicit mid-
wives’ involvement in giving pregnant women
information, and assisting them to decide where
to give birth. Unstructured interviews were
conducted by the researcher (BCM) at the
women’s own homes; each participant was
interviewed only once.
Access and ethical considerations
The study was conducted in two areas in the
South-East of England using one hospital in each
area as a base for recruiting women. Ethical
approval was obtained from one research ethics
committee that served both hospitals.
During the planning stages of the study,
midwifery managers at the two hospitals were
contacted to discuss the proposal, and possible
use of their maternity units for conducting the
study. The managers consulted with the relevant
consultant obstetricians and general practi-
tioners and they collectively gave permission
for the study to be conducted. Once research
ethics approval had been gained, meetings were
held with midwives at the two maternity units to
ARTICLE IN PRESS
Available options for childbirth venue 329
discuss the study and how the midwives
could help. Midwives at the two hospitals were
divided into two teams, those assigned to work in
the community, and those who were based in the
hospital. For the purpose of the study, the
researcher worked with both teams. Community
midwives were consulted about women who were
planning a home birth, and hospital midwives
about women who were planning a hospital
birth. It was agreed that midwives would
distribute information leaflets explaining the
study to potential participants during antenatal
visits and ask if they would be interested in
participating. This approach was taken because
it was felt that women would not feel pressured
to participate if asked by their midwives rather
than a stranger. As well as explaining the
purpose of the study, the information leaflets
explained that participation in the study would
involve one interview at the woman’s chosen
place. The potential participants were also
clearly informed that they could refuse to
participate without any prejudice to their normal
care, and that if they chose to participate they
could still withdraw at any time. Women who
showed interest in participating were asked to
sign consent to be contacted by the researcher by
telephone to discuss a convenient time and place
to meet to discuss the study further and possibly
conduct the interview.
After the study was explained by the research-
er, participants were asked to sign a consent
form to participate in the study and to have the
interviews tape-recorded for later transcription
and analysis. At the interview stage each woman
was given a foreign pseudonym and was referred
by it during the interview so that the transcript
would identify her as such to disguise her
identity.
Par ticipants
Pregnant women were invited to participate in
the study if they met the following criteria:
*32--42 weeks of pregnancy.
*Low obstetric risk pregnancy; including sin-
gleton pregnancy, no known complications,
cephalic presentation.
The criteria were chosen because women of
low obstetric risk are unlikely to have restrictions
on where they could give birth. Secondly, it was
thought that in the second trimester women
might have started thinking about where they
might want their babies to be born, and that the
midwives might also have started to talk to them
about options for childbirth venue.
Two groups of women were selected, one
comprising 20 women planning a hospital birth
and another made up of 13 women planning a
home birth. The home birth group included all
women who were in the home birth antenatal
register at the time of the study. The hospital
birth group comprised a purposefully chosen
sample from the hospital birth antenatal register.
Data collection
All participants preferred to be interviewed in
their homes. Prior to the interview, participants
were reminded of the objectives of the study and
asked if they had any questions about the study,
particularly the content of the information
leaflets. They were reminded that participation
in the study was voluntary, and that they could
stop the interview at any time if they did not
wish to continue. The researcher then asked
an open question about how they made the
decision about where they were going to give
birth; the question was asked as a continuation
of the conversation that had already started at
the beginning of the meeting. There was a
question guide intended for use if the participant
was not forthcoming with information. The
question guide included areas of discussion such
as, how much the woman knew about the
options that were available, what the source of
the information was, how the midwife was
involved, when the decision was made, who
was involved, and the main reason for preferring
their chosen place to the alternative place. All
interviews were tape-recorded with the partici-
pant’s permission. Notes were also made about
the interview soon afterwards. Information
about the participants’ demographic variables
was extracted from their antenatal records.
Data analysis
The process of data analysis was iterative with
data collection, after the first interview was
conducted, it was immediately transcribed verba-
tim and the transcript checked against the
recording for accuracy. The transcript and
accompanying notes were read and re-read then
analysed by hand using open coding (Glaser 1992)
to identify emerging themes as indicated by
significant words and sentences. A pictorial
representation of all the categories and themes
that came out of the interview was drawn. The
findings of the analysis of the first interview were
used to guide the subsequent interview and the
process continued like that until the last interview.
The constant comparative method of analysis
(Glaser & Strauss 1967,Strauss & Corbin 1990)
was employed, where all data relevant to a
category are identified and examined and com-
pared to the rest of the data. The iterative
process of interview--analysis--interview allowed
questions to be refined, or more questions to be
asked for clarification of points made earlier.
ARTICLE IN PRESS
330 Midwifery
Theoretical sampling (Patton 1980,Guba &
Lincoln 1985,Morse 1989,Strauss & Corbin
1990,Kuzel 1992) was used, where subsequent
participants are chosen because of the possible
contribution they could make to the already
developing story line as suggested by the
analysis. For example, the first three women
interviewed from the hospital group were all
unmarried and they mentioned that they had not
discussed the issue of where the baby was going
to be born with their partners. The researcher
wanted to understand why there was such a
pattern. Therefore the next participant from the
hospital group was purposefully chosen as
married, and a deliberate decision was made to
ask her whether she had discussed the place of
delivery with her partner. This helped to under-
stand the context of the theme that was emerging
from the data.
The process of data collection and analysis
continued until no new findings were forth
coming, this stage was considered to be the data
saturation stage (Morse 1989, 1995). Another
researcher, not involved in the study repeated the
analysis for a third of the transcripts and came
up with similar findings.
FINDINGS AND DISCUSSION
All women who were invited to participate in the
study did. All were of British, Caucasian origin
except for one whose origin was Indian. The age,
marital status, and parity of those who partici-
pated are presented in Table 1. Women in the
home birth group had more college and uni-
versity degrees than those in the hospital birth
group. Other studies have also found women
planning a home birth to be generally better
educated (Cohen 1982,Schneider 1986,Eakins
1989,Rooks et al. 1989,Soderstrom et al. 1990).
There was only one woman in the home birth
group expecting her first baby, whereas in the
hospital group there was an even distribution of
parity. This finding is in line with those of other
studies, which found an under representation
of first-time mothers in out-of-hospital births
(Cohen 1982,Schneider 1986,Littlefield &
Adams 1987,Howe 1988,Rooks et al. 1989,
Anderson & Greener 1991,Viisainen et al. 1998).
Information was found to be one of the main
themes in the findings. The women’s preferences
for a place of birth seemed to be influenced by
what information they had about available
options. Under the main theme of information,
subcategories of ‘presumption of a hospital
birth’, ‘midwives’ involvement’, ‘partners’ invol-
vement’ and ‘influence of others’ emerged. The
subcategories emerged because:
*some women assumed that they were going to
give birth in hospital (assumption of hospital
delivery);
*some had discussions with their partners
about the place of delivery while some had
not (partners involvement);
*others referred to the discussions they had
with their midwives (midwifes involvement);
*some had friends or neighbours who had had
babies at home which encouraged them in
their choices (influence of others).
Presumption of a hospital delivery and
midwife’s involvement
Most women planning a hospital birth had
assumed that the hospital was the only place to
go. Women seemed to have come to the
assumption because no one had talked to them
about what other options were available:
Well, I am having it at (name of hospital)
because, basically there is nowhere else to
have it, I don’t think. (Tshidi, hospital)
I don’t know how I came to the decision that I
am going to have my baby in hospital; um
(pause) I suppose I probably assumed from
the start that I would. I have always presumed
that it would be at the hospital. I didn’t even
think about having it at home, I don’t know
why I didn’t even consider it... I have never
known anybody to have a baby at home
before. I just presumed that was the normal
thing to do you know. (Gaboelwe, hospital)
I think you just grow up knowing you are
going to have your baby in hospital. Just, you
know, you immediately think that you are
going to have your baby in hospital. I didn’t
really give home birth a thought and I
ARTICLE IN PRESS
Ta b l e 1 Characteristics of women in the study
Characteristic Home birth Hospitalbirth
n=13 n=20
Age
20 --2 5 2 4
26 --31 4 6
32--37 6 8
38--43 1 2
Marital status
Married 10 3
Single 15 5
Number of pregnancies
First 1 6
Second 4 5
Third 6 6
Fourth 2 3
Education
Primary 3 8
Secondary 5 7
University/college 5 5
Available options for childbirth venue 331
just had hospital in mind really. (Segosha,
hospital)
Some women specifically said that their mid-
wives encouraged them to go to a particular
hospital or gave them a choice between the two
hospitals in the area:
Oh it’s only been a choice of hospital; I can’t
even remember being asked the question
whether I wanted a home birth. I was given
the choice of two hospitals, basically [1 or 2],
but again I suppose I was familiar with 1, I’d
had a baby there I was more than happy with
the care that I got there so I saw no reason
to go and change to a different hospital.
(Montlenyane, hospital)
I wouldn’t say a 100%, but I think they really
want you to go to hospital. I would say that
they give the information that they have to
give, but they would slightly, not force you,
that’s the wrong word, but in the way that it’s
presented and the rest of it would encourage
you to go to [name of hospital]. Yes, you
would probably be encouraged that way.
(Boithatelo, hospital)
Some women mentioned that they thought one
had to indicate interest in having a home birth
for the option to be considered:
I think a lot of them make an assumption and
think well, yes, you come under [name of
hospital] or [another hospital] or whatever and
say, ‘you will be going along there to have the
baby, won’t you?’ And, people, unless they
have specifically thought about it and are
willing to state, ‘well, actually, no, I won’t,’
then they will not get the option at all. You do
have to ask about things, and even when I said
I want a home birth, I already knew the process
because I had spoken to my neighbour about
it, but there was nothing given to me. You have
to go looking for it or ask for the information
yourself definitely. (Maipelo, homebirth)
I don’t really remember anybody telling me
about the options of home and hospital birth.
I think it is just presumed that is the decision
you make and if you are not giving any other
decisions you are sort of rail-roaded into that
scenario and you don’t think of anything else
(hospital birth). (Pedzani, hospital)
The findings that women felt they were not
given information about options for childbirth is
in tandem with findings of other studies that
looked at different aspects of satisfaction with
provision of maternity services and found that
women feel they are often not offered a choice
about their care (MORI 1993, Gready et al.
1995,Davies et al. 1996,Chamberlain et al. 1997,
Davies 1997,Garcia 1999). These findings there-
fore support the argument made by other
researchers and commentators that women
are being persuaded to give birth in hospital
(Bathgate & Ryan 1995,Devenish 1996,Leap
1996,Pengelley 1996,Walcott 1997,Warshal
1997,Stapleton 1997,Hosein 1998,Kargar
1998). Others have argued that consumer choice
is limited to the services on offer, such that those
who extol choice also define the choices available
(Kirkham & Perkins 1997). The view of the
House of Commons Health Committee is that
the available choices are ‘often more illusory than
real’(House of Commons Health Committee
1992, para 51).
Some women mentioned that their midwives
asked them where they were going to deliver, and
the response to this question was always the local
hospital. The researcher wanted to know why this
question was interpreted this way and therefore
some of the participants were asked what choice
they thought the question implied. The following
is a conversation between the researcher and one
participant about that question:
I was just asked where I wanted to have my
baby and when I said (name of hospital) that
was it, it wasn’t taken any further they didn’t
even explain the difference between the two
hospitals. (Mampenene, hospital)
Researcher: When you were asked where you
wanted to have your baby, what did you
understand the question to mean?
Just the literal, what (pause), I wasn’t asked
about wanting a home birth or anything like
that. I wasn’t asked if I wanted a home birth.
I just took it to mean which hospital I want to
go to. (Mampenene, hospital)
It appears from the interaction above that the
way information was presented may have had an
impact on how women understood it. The
question could have meant either;
1. Was she going to have the baby at home or
in hospital, or
2. Which of the two hospitals was she going to.
The woman above and others planning a
hospital delivery, understood the question to
mean the latter.
It was evident, particularly among women
planning a home birth, that if you knew about
the availability of home birth, and wanted that
option then the midwives were willing to listen
and sometimes even supportive of the choice:
My main midwife, she just said to me, if you
want to have it at home you can have it at
home, that’s no problem. So she was suppor-
tive, she didn’t sort of try and persuade me
ARTICLE IN PRESS
332 Midwifery
one way or the other, that was really her only
comment on it. (Bonyana, home)
I went for my 28-week check and was very
nervous about mentioning it to the midwife. I
thought I can’t possibly ask for a home birth
for my first baby, but I did and the idea was
welcomed by the midwife. (Segametsi, home)
An interesting finding was that although some
women felt that they should be informed about
all the options of where to have a baby, most
women who were planning a hospital birth were
protective of their planned place of delivery, and
felt that it probably would not have made any
difference to their choice if they had been
informed of the availability of home as a possible
venue for childbirth:
I think at the booking visit I was asked which
hospital I would be going to, home birth
wasn’t mentioned. Now we are talking about
it, I think perhaps it should have been
mentioned as a matter of course. But I feel
personally that I, you know, that I’m intelli-
gent enough to decide whether I want to ask
about it, and then I’d make a decision that
way. But I suppose it wouldn’t instill a lot of
confidence in people if it wasn’t mentioned at
all, and they were there thinking, well, actually
I think I like the idea of a home birth If you
then just ask which hospital would you like to
go to, I suppose it makes it difficult to say I’d
rather have it at home. (Leungo, hospital)
Home birth is not something I would have
wanted anyway, but it wasn’t mentioned.
(Mampenene, hospital)
I mean you only ever know as much as
anybody ever tells you or you bother to find
out. I am sure there’s lots more information if
I can be bothered to find out and things, you
know, I can get and do. But I mean, I think
you only, I personally only asked as much
information as I particularly want to know
and once I’ve got all the information I
particularly need them I’m happy, so, you
know, I’m happy with the package that I’ve
got. (Boithatelo, hospital)
This finding resonates with that of an earlier
study that found that women are usually happy
with the care that they receive whatever it is
(Porter & Macintyre 1984).
Partner’s involvement
There was a distinct difference between women
planning a home birth and those planning a
hospital birth with regard to their partner’s
involvement in the decision making. All women
in the home birth group had discussed the issue
of place of birth with their partners or husbands.
Some of the women’s partners were very
supportive of their home birth choice, but some
were not in support of home birth initially, but
after discussions with their partners they came to
support them:
My husband said to me, whatever you want is
fine by me. So, yes, he is quite understanding
and just said well, I can’t understand why you
want to have it at home, but I’m with you a
100%. (Gaolape, home)
At first he was apprehensive. He is American
and they are very used to birth being a very
medical thing yhis mother had five caesarean
sections, so his attitude was initially was very
negative but he came round so quickly, it was
like probably took less than a day to convince
him. (Senyana, home)
My husband and I had an argument about it
last night (pause). He is frightened, he is very
frightened. My husband is just, just hasn’t got
the faith that I have because he hasn’t got the
knowledge that I have despite what I tell
himy. But it is a two-way thing, I can’t do
this without my husband’s support and I must
respect his decision and his attitude. (Nnese,
home)
On the other hand, most women who were
planning a hospital birth had not discussed the
place of delivery with their partners:
We never really discussed it because we knew
when [name of hospital] closed down, we just
thought oh well, next time we have a baby it
will be at [name of hospital]. So, um, yes, it
wasn’t something we discussed, it was just,
that was where we were going to go.
(Olebogeng, hospital)
We just assumed it would be in hospital, we
didn’t really talk about it. We didn’t discuss it
at all. (Gaboelwe, hospital)
The finding that women who were planning a
hospital birth had not discussed where they were
going to give birth with their partners may
strengthen the argument that these women did
not know that there was another option apart
from the hospital, and therefore there was no
point in discussing the obvious. Actually, some
of the women were asked why they did not
consider a home birth and the reaction was that
it was not mentioned:
When someone plants a seed of thought in
your head, like perhaps home birth, and gives
you some information, you may consider it
more, but because that seed was never
ARTICLE IN PRESS
Available options for childbirth venue 333
planted, I didn’t even consider it (hospital).
(Gaboelwe, hospital)
Influence of others
The subcategory of influence of others applies
only to women who were planning a home birth.
Most of them mentioned someone they knew
who had a home birth and said that their positive
experiences had either influenced or encouraged
them to pursue their home birth:
I suppose you are idealistic to a certain extent
but the lady who is down the road who has
had two babies at home just said that the
experiences didn’t compare. You know, hav-
ing a baby in hospital or having a baby at
home is, was just so different and it was just
relaxed and you just had the baby and carried
on. (Segametsi)
My neighbour next door also had an influence
because she had a baby six months ago and
she had a home birth. (Maipelo)
Summary
In this qualitative study some insight into the
specific role played by midwives in the South-
East of England in pregnant women’s decision
making about the place of delivery has been
provided. A reflective perspective by pregnant
women about how they decided on where they
were going to give birth has also been presented.
The nature of the study implies that findings
cannot be generalised to other populations.
However, because data were collected and
analysed until saturation, the identified issues
may be relevant to other pregnant women in
similar circumstances. Other researchers have
identified that women are not given adequate
information about services on offer. The present
study adds to the existing knowledge, and goes
further by allowing women to reflect on circum-
stances leading to their planned place of delivery.
Women were encouraged to reflect on how their
midwives were either stepping-stones or impedi-
ments in the decision-making.
The findings would suggest that midwives may
not be comfortable with freely giving out
information about home birth but it was beyond
the limits of the study to ask midwives their
reasons. Some studies have suggested that mid-
wives view childbirth in a medical fashion
(Olsson et al. 2000), while others feel that
midwives fear being blamed (Kirkham 1999)
and are therefore disempowered.
Implications for practice
The central aim of Changing Childbirth (DoH
1993) is for midwives to uphold the principle of
informed consent and maximise opportunities
for women to make choices about their care,
including the choice of where to give birth, but
studies are still suggesting that women are not
informed. More efforts are therefore needed to
tackle the problem of midwives’ failure of their
duty to inform women. Talking to women about
their services and their rights and choices is one
of the ways that could help in providing truly
woman-centred care, and the principle of in-
formed choice and consent is fundamental to
good maternity care.
It is fitting to end by giving a quotation from
one of the women who took part in the study
who said:
I think we need to educate our midwives and
suss out why midwives are so against home
births, some midwives are and some midwives
aren’t. y. but the midwife has to be very
unbiased in giving an informed choice and I
think most (pause), some midwives are biased
to hospital births. (Nnese, home birth)
ACKNOWLEDGMENTS
This study was fully funded by the European Institute of
Health and Medical Sciences, University of Surrey as part
of a PhD study by Banyana Cecilia Madi.
REFERENCES
Anderson A, Greener D 1991 A descriptive analysis of
home births attended by CNMs in two nurse-
midwifery services. Journal of Nurse-Midwifery 36:
96--103
Bathgate W, Ryan MHM 1995 Divided views among
health professionals on place of birth. British Journal
of Midwifery 3(11): 583--587
Campbell R, Macfarlane A 1994 Where to be born? The
debate and the evidence 2nd edn. National Perinatal
Epidemiology Unit, Oxford
Chamberlain G, Wraight A, Crowley P 1997 Home births:
the report of the 1994 confidential enquiry by the
National Birthday Trust Fund. Parthenon Publishing
Group, London
Churchill H, Benbow A 2000 Informed choice in
maternity services. British Journal of Midwifery
8(1): 41--47
Cohen RL 1982 A comparative study of women choosing
two different childbirth alternatives. Birth 9(1):
13--19
Coyle K, Hauck Y, Percival P, Kristjanson L 2001
Ongoing relationships with a personal focus: mothers’
perceptions of birth centre versus hospital care.
Midwifery 17: 171--181
Cunningham JD 1993 Experiences of Australian mothers
who gave birth either at home, at a birth centre, or, in
hospital labour wards. Social Science & Medicine
36(4): 475--483
Davies J 1997 The midwife in the Northern Region’s 1993
homebirth study. British Journal of Midwifery 5(4):
219--224
Davies J, Hey E, Reid W, Young G 1996 Prospec-
tive regional study of planned home births. BMJ
ARTICLE IN PRESS
334 Midwifery
313(7068): 1302--1306. http://bmj.com/cgi/content/
abstract/313/7068/1302
Department of Health (DoH) 1993 Changing childbirth,
Part I: report of The Expert Maternity Group (chair,
Lady Cumberlege) HMSO, London
Department of Health and Social Security 1970 Dom-
iciliary midwifery and maternity bed needs: report of
the sub-committee (chair, Sir John Peel) HMSO,
London
Department of Health and Social Services Northern
Ireland 1994 Delivering choice: the report of the
Northern Ireland maternity unit study group. DHSS,
Belfast
Devenish S 1996 Home birth: the midwife’s dilemma.
MIDIRS Midwifery Digest 6(1): 9--12
Dowswell T, Renfrew MJ, Gregson, Hewison J 2001
A review of the literature on women’s views on
their maternity care in the community in the UK.
Midwifery 17: 194--202
Eakins P 1989 Free standing birth centers in California:
program and medical outcome. Journal of Reproduc-
tive Medicine 34: 960--970
Floyd L 1995 Community midwives views and experience
of home birth. Midwifery 11: 3--9
Fordham S 1997 Women’s views of the place of
confinement. British Journal of General Practice 47:
77--81
Garcia J 1999 Mothers views and experiences of care. In:
Marsh G, Renfrew MJ (eds) Community-based
maternity care. Oxford University Press, Oxford
Glaser BG 1992 Basics of grounded theory analysis:
emergence vs forcing. Sociology Press, Mill Valley
Glaser BG, Strauss AL 1967 The discovery of grounded
theory: strategies for qualitative research. Aldine,
Chicago
Gready M, Newburn M, Dodds R, Gauge S 1995 Birth
choices: women’s expectations and experiences.
National Childbirth Trust, London
Guba EG, Lincoln YS 1985 Effective evaluation: improv-
ing the usefulness of evaluation. Results through
evaluation and naturalistic approaches. Jossey Bass,
San Francisco
Hosein M 1998 Home birth: is it a real option? British
Journal of Midwifery 6(6): 370--373
House of Commons Health Committee 1992 Health
Committee Second Report, Session 1991--92: Mater-
nity Services (chair Nicholas Winterton). HMSO,
London
House of Commons Social Services Committee 1980
Perinatal and neonatal mortality: second report,
session 1979--1980. HMSO London
Howe K 1988 Home births in South-West Australia.
Medical Journal of Australia 149: 296--301
Hundley V, Rennie A-M, Fitzmaurice A, Graham W,
Teijlingen E, Penney G 2000 A national survey of
women’s views of their maternity care in Scotland.
Midwifery 16: 303--313
Jacoby A 1988 Women’s views about information and
advice in pregnancy and childbirth: findings from a
national study. Midwifery 4: 103--110
Jones O, Smith S 1996 Choosing the place of birth. British
Journal of Midwifery 4(3): 140--143
Kargar I 1998 Concerning rotten apples and barrels.
Midwifery Matters (77): 4--5
Kirkham MJ 1999 The culture of midwifery in the
national health service in England. Journal of
Advanced Nursing 30: 732--739
Kirkham MJ, Perkins ER 1997 Reflections on midwifery.
Bailliere Tindall, London
Kleiverda G, Steen A, Anderson I, Treffers P, Everaerd W
1990 Place of delivery in the Netherlands: maternal
motives and background variables related to prefer-
ences for home or hospital confinement. European
Journal of Obstetrics and Gynecology and Repro-
ductive Biology 36: 1--9
Kuzel AJ 1992 Sampling in qualitative inquiry In:
Crabtree BF, Miller WL (eds) Doing qualitative
research, Vol. 3. Sage, Newbury Park
Leap N 1996 Persuading women to give birth at home
or offering real choice? British Journal of Midwifery
4(10): 536--538
Littlefield VM, Adams BN 1987 Patient participation in
alternative perinatal care: impact on satisfaction and
health locus of control. Research in Nursing and
Health 10: 139--148
Mackey MC 1990 Women’s choice of childbirth
setting. Health Care For Women International 11:
175--189
Mander R 1993 Who chooses the choices? Modern
Midwife 3(1): 23--25
Market Opinion Research Institute 1993 Maternity
services report: research study conducted for the
Department of Health. Department of Health,
London
Mather S 1980 Women’s interest in alternative maternity
facilities. Journal of Nurse-Midwifery 25(3): 3--10
Mckay S, Smith SY 1993 What are they talking about?
Is something wrong? Birth 203: 142--147
Ministry of Health 1959 Report of the Maternity Services
Committee (Cranbrook report). HMSO, London
Morse JM 1989 Qualitative nursing research: a contem-
porary dialogue. Sage, Newbury Park
Morse JM 1995 The significance of saturation. Qualitative
Health Research 5(2): 147--149
Murphy PA, Fullerton J. 1998 Outcomes of intended
home births in nurse-midwifery practice: a prospec-
tive descriptive study. Obstetrics and Gynecology
92(3): 461--470
O’Cathain A, Thomas K, Walters SJ, Nicholl J, Kirkham
M 2002 Women’s perceptions of informed choice in
maternity care. Midwifery 18: 136--144
Oakley A 1979 Becoming a mother. Martin Robertson,
Oxford
Olsson P, Jansson L, Norberg A 2000 A qualitative study
of childbirth as spoken about in midwives’ ante- and
postnatal consultations. Midwifery 16: 123--134
Patton MQ 1980 Qualitative evaluation and research
methods, 2nd edn. Sage Publications, Newbury Park
Pengelley L 1996 GP’s and home birth. New Generation
Digest 16: 4--5
Porter M, Macintyre S 1984 What is must be best: a
research note on conservative or deferential responses
to antenatal care provision. Social Science & Medi-
cine 19(11): 1197--1200
Ralston R 1994 How much choice do women really have
in relation to their care? British Journal of Midwifery
2(9): 453--456
RCM 2002 Position paper 25: home birth. RCM Mid-
wives Journal 5(1): 26--29
Reid ME, Mcllwaine GM 1980 Consumer opinion of
a hospital antenatal clinic. Social Science & Medicine
4: 363--368
Rooks J, Weatherby N, Ernst E, Stapleton S, Rosen D,
Rosenfield A 1989 Outcomes of care in birth centers:
the national birth center study. New England Journal
of Medicine 321: 1804--1811
Russell J 1982 Perinatal mortality: the current debate.
Sociology of Health and Illness 4(3): 302
Schneider D 1986 Planned out of hospital births. New
Jersey 1978--1980. Social Science & Medicine 23:
1011--1015
Scottish Office 1993 Provision of maternity services: a
policy review. The Scottish Office, Edinburgh
Singh D, Newburn M, Smith N, Wiggins M 2002 The
information needs of first-time pregnant mothers.
British Journal of Midwifery 10(1): 54--58
ARTICLE IN PRESS
Available options for childbirth venue 335
Soderstrom B, Stewart PJ, Kaitell C, Chamberlain M 1990
Interest in alternative birth places among women in
Ottawa-Carleton. Canadian Medical Association
Journal 142(9): 963--969
Stapleton H 1997 Choice in the face of uncertainty In:
Kirkham MJ, Perkins ER (eds) Reflections on
midwifery. Bailliere Tindall, London
Strauss AL, Corbin J 1990 Basics of qualitative research:
grounded theory procedures and techniques. Sage,
Newbury Park
Tew M 1977 Where to be born? New Society 39:
120--121
Tew M 1985 The place of birth and perinatal mortality.
Journal of The Royal College of General Practi-
tioners 35: 390--394
Tew M 1990 Safer childbirth? A critical history of
maternity care, 2nd edn. Chapman & Hall, London
Viisainen K, Gissler M, Raikkonen O, Perala ML 1998
Interest in alternative birth settings in finland.
Acta Obstetricia et Gynecologica Scandanavica 77:
729--735
Walcott L 1997 Achieving a home birth. Midwifery
Matters 75: 10--11
Waldenstrom U, Nilsson CA 1993 Characteristics of
women choosing birth center care. Acta Obstetricia
et Gynecologica Scandanavica 72: 181--188
Warshal S 1997 Home birth hassles. AIMS Journal 8(4):
3--5
Welsh Office 1991 Protocol for investment in health gain:
maternal and early child health. DHSS, Cardiff
ARTICLE IN PRESS
336 Midwifery
... Maternity care had changed dramatically since the 1910s. While almost all births took place at home in the early part of the twentieth century, by 1960, approximately half of women delivered in hospital, rising to 98% of women by the early 1980s (32). In 1979, Oakley was one of the earliest to speak at length in her narrative of postnatal depression about how her experience of birth affected her subsequent mental health (3). ...
... There are notable differences between their experience; where Busby felt belittled and objectified by the attending medical staff (22), Shields lauded her obstetrician as "nurturing" (4). Indeed, the issues faced by Busby, highlighted by women such as Oakley and Coles in preceding decades, had been acknowledged by two successive government reports in the 1990s, The Winterton Report (1992) and The Cumberlege Report (1993) (32). Both reports advocated for choice and involvement of women in the delivery of their baby and crucially "the right for women to have control over their own body at all stages of pregnancy and birth" (32). ...
... Indeed, the issues faced by Busby, highlighted by women such as Oakley and Coles in preceding decades, had been acknowledged by two successive government reports in the 1990s, The Winterton Report (1992) and The Cumberlege Report (1993) (32). Both reports advocated for choice and involvement of women in the delivery of their baby and crucially "the right for women to have control over their own body at all stages of pregnancy and birth" (32). ...
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... However, women's accounts demonstrate that midwives can be vague in providing appropriate information about birthplaces that would facilitate women's informed choices and decision-making . Madi and Crow (2003) identified a midwife's 'reluctance' to give unbiased information to the women. Barber et al. (2006) offered a different explanation regarding that phenomenon. ...
... Some studies concluded that women choose to give birth at home because they feel safe, and other studies found that women only feel safe in hospital. Women's right to choose is closely related to the availability of information and their relationships with health professionals (Madi and Crow, 2003;Barber et al., 2006). Women's autonomy plays an important role in maximising safety and decisionmaking, but it should be developed within the context of trusting relationships between women, health professionals and health systems (Madi and Crow, 2003;. ...
... Women's right to choose is closely related to the availability of information and their relationships with health professionals (Madi and Crow, 2003;Barber et al., 2006). Women's autonomy plays an important role in maximising safety and decisionmaking, but it should be developed within the context of trusting relationships between women, health professionals and health systems (Madi and Crow, 2003;. ...
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... Previous qualitative [19,20] and quantitative studies [11,[21][22][23][24] from the early 1990s through to 2011 (reviewed more fully elsewhere [4]) found that women were not necessarily aware that choice existed or believed that the only available choices were between OUs. However, in some studies there were examples illustrating that some women were adequately informed and supported in their decisions by their health care professionals [11,25,26]. ...
... Many women in our study had sought out information from other sources rather than being provided with information through a single channel by their midwife; some had to ask questions in order to get information about their options, and others had come across relevant information by chance. Friends and family, [20,30,[33][34][35], word of mouth [33,35] and women's personal experiences of birth [19,27,29,33,[36][37][38][39] were important influences on women's decisions, as has been found previously but the Internet appears to have become a much more important source of information than has been reported in previous studies. ...
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