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:
‘… four national choice guarantees [choice of how to access maternity care, type of antenatal care, place of birth and postnatal care] will be available for all women by the end of 2009 and women and their partners will have opportunities to make well-informed decisions about their care throughout pregnancy, birth and postnatally’ (DH 2007b:5)
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:
’The overall goal has to be that women are enabled to make decisions that make them feel more powerful, wherever they are and with whoever attends them when they give birth. They can only feel safe, secure and protected if they know that their concerns will be respected and their integrity and autonomy will be preserved.’(Leap & Edwards 2006:103)
Reflective activity 34.1