Introduction
This chapter covers a variety of topics exploring programmes of care during childbirth, with choice as its central theme. The government’s aspirations for women to have choice regarding their place of birth are a central theme for governmental policy (DH 2010) and this is therefore an important element to consider within this chapter. Place of birth is discussed – hospital, homebirth and birth centre. Choices for women are discussed and include the importance of information giving to ensure that choices of care are fully informed. The Department of Health (DH 2010) outlines how equity and excellence can empower and liberate both women and their clinicians. Models of care are discussed, including the different types of midwifery care provision available to women. Childbirth preparation classes are explored, looking at programmes of education that parents are offered and planning for childbirth.
How we arrive at our choices may be deep-rooted. Sometimes we don’t even know how we get there. It is not our role to judge a woman who makes decisions very different from the ones we would choose for our families or ourselves.A woman can choose from a variety of models when planning her care during pregnancy and childbirth. A midwife is skilled and qualified to care for the woman from conception through to birth and the postnatal period. However, in the UK most women see their GP as the first point of contact. GPs may not be expert in the different options for maternity care. The House of Commons Health Committee (2003) describes how some women were frequently referred by their GPs to consultant-led care, thereby limiting choice for women who may be experiencing a normal pregnancy. It was also discovered that women often found it difficult to access maternity care without a referral from their GP. A study undertaken by the National Childbirth Trust (NCT) in 2009 discovered that around 40% women felt that they did not have a choice as to where they gave birth (Dodwell & Gibson 2009).
The National Service Framework (NSF; DH 2004) standard for maternity services states that the midwife should be the first port of call for women when they discover they are pregnant. The House of Commons Health Committee (2003) cites several interesting comments regarding consumer organisations and their opinions concerning choice in maternity services – according to Beech (House of Commons Health Committee 2003), ‘Choice is an illusion. The majority of women are conned into thinking they have a choice’, while Phipps (House of Commons Health Committee 2003) talks of ‘informed compliance rather than informed choice’.
It is essential that the midwife is aware of the choices that the woman can make and provides her with up-to-date information so that she can make informed decisions in partnership with the midwife. The Birthplace Plus Study (Birthplace in England Collaborative Group 2011) has validated the latest policy of ensuring that low-risk women are offered a range of birthplace choices. The study found that birth in midwifery-led units and midwifery-led care are safe for the mother and baby and that these are the best places for low-risk women to give birth. Interestingly, the study discovered that low-risk women planning to give birth in consultant-led units were three times more likely to have an emergency caesarean section, twice as likely to have an instrumental delivery, need a blood transfusion, need intensive care and suffer severe perineal trauma compared to low-risk women choosing to give birth at home or in a midwifery-led unit. These are important findings to share with women when helping them make an informed decision as to where to give birth.
The different places where a woman can choose to give birth will now be explored.
Place of birth
A woman has a number of options when thinking about the place in which she wishes to give birth. For most women, pregnancy and birth is a healthy, exciting and special episode. It is important that the woman makes the choice that is right for her and her family. Options need to be woman centred and focused on meeting the needs of the individual rather than the service. The DH (2010) outlines how personalised care and increased choice can strengthen women’s voices, empowering them to make informed decisions. The Birthplace Plus Study (Birthplace in England Collaborative Group 2011) can provide midwives with facts about the health outcomes that birthing in different areas may produce. This is an important and robust study into health outcomes and should be included in discussions with women and couples when they are choosing their place of birth.
Hospital with a central delivery suite
A woman may choose to give birth in a hospital and indeed this is where the majority of babies in the UK are born (Birth Choice UK 2007). Women who have complicated or high-risk pregnancies are offered consultant-led care and the consultant obstetrician will be the lead carer. Examples of pregnancies deemed to be high risk are in women who develop high blood pressure and pre-eclampsia; women with pre-existing medical conditions; and women who are carrying more than one baby. However, for women who do develop complications, there needs to be a team approach, bringing together the skills of midwives, obstetricians, paediatricians and anaesthetists to ensure seamless care for the woman. The Department of Health’s (2011) 8th Confidential Enquiry into Maternal Deaths (2006–2008) makes reference to the importance of teamwork in many areas where substandard care has been uncovered.
Healthy women who choose to give birth in hospital do so for a variety of reasons. The woman may feel safer there or wants the reassurance of knowing that an anaesthetist is on hand if she chooses to have an epidural. However, some women may be unaware that they have other options than to go to hospital. In a study about women’s choices undertaken by Lavender (2003), it was highlighted that women were reassured by the medical facilities a large consultant unit offered, especially in the event of an emergency. Lavender (2003) attributed this to women’s lack of knowledge of the choices available to them and the fact that a medically oriented approach was perceived to be safer than midwifery-led care. Women should be given the opportunity to familiarise themselves with the delivery suite by having a guided tour with the midwives and midwifery assistants who work there. Where it is known that a woman’s baby is likely to spend time in a special care baby unit, she should be offered the chance to visit it and meet members of the team.
My local hospital has a birth centre attached to it. Most of my friends have had their babies there. I must admit that I am petrified of the pain and want to have an epidural as soon as I go into labour! The midwife has said that I should try the birth centre as it is very homely and has two birthing pools. I don’t care about the wallpaper, I just care that there is an anaesthetist on standby as soon as I have the first contraction. I want every drug going.I am one of the last of my friends to have a baby and have heard so many horror stories of tearing, hours of agony and losing lots of blood and I really don’t want to feel anything. If I could have a planned C section, I would but the midwives have told me this is not possible. If I had the money, I would pay for this privately.
Postscript: I am writing this holding my baby boy! When I arrived at the midwifery-led unit I was already 8 cm dilated!! I really wanted them to take me downstairs to the main unit to have an epidural but the midwife who was looking after me was so kind and lovely that she was able to calm me and reassure me. I was even persuaded to get into a birth pool! I gave birth using a bit of gas and air and did not even tear. Looking back, I am so pleased I gave birth normally as I was up and about so quickly. I am now a bit evangelical about childbirth. My friends cannot believe my change in attitude.
Birth centres
Birth centres are also known as stand-alone birth centres, free-standing birth centres or midwifery-led units. They are facilitated and managed by midwives and often have consumer involvement from women who have used the birth centre previously and members of Maternity Services Liaison Committees (MSLCs) and the National Childbirth Trust (NCT). Staffing usually includes midwives, midwifery assistants and housekeepers. Birth centres often provide antenatal care and postnatal support, as well as facilitating parenthood education.
Being midwifery led, birth centres take the focus away from the medical model and concentrate on the social model of care. With regard to medical facilities, birth centres are the same as what is expected from a homebirth – should intervention be required, the woman would be transferred to a hospital just as if she were transferring from home. Birth centres have a wealth of benefits and these have been outlined by Walsh & Downe (2004) and more recently the Birthplace Plus Study (Birthplace in England Collaborative Group 2011):
- Increased normal birth rates
- Fewer assisted births using instruments such as forceps and ventouse
- Reduced caesarean section rate
- Fewer women using strong pain-relieving drugs, such as pethidine and diamorphine
- Fewer women using epidurals
- Reduced rates of induction of labour
- Fewer women needing episiotomies
- Fewer vaginal examinations
- Shorter labours
- Reduced incidence of shoulder dystocia (when the baby’s shoulder becomes impacted behind the woman’s pubic bone)
- More intermittent fetal monitoring and less use of continuous electronic monitoring
- Higher maternal satisfaction
- Increased midwifery job satisfaction
- Increased breastfeeding success
- Cost-effective
Walsh (2005) defines a birth centre as a place that provides midwifery care in childbirth, with importance placed on relationships and the environment rather than on machinery and drama. Many birth centres offer birthing pools or large baths as pain relief and may have options for low lighting, birth balls, birth stools and music. The environment in a birth centre usually facilitates normality. The birth environment is important to women and has been highlighted in the NSF (DH 2004) and by the NCT (Dodwell & Gibson 2009). The NCT issues awards for midwifery-led units that facilitate the best birthing environments for women with the aim of celebrating innovations in practice that enhance women’s experience of labour and birth. Lavender (2003) found that many women believed that a midwifery-led unit on the same site as a consultant unit offered safety but with a more homely environment, and 51% of women said that it was important to them to have a midwife help them to give birth naturally without medical intervention.
I was the 100th mum to give birth in the Hemmingway birth centre. It is such a great environment to give birth. The midwives and staff are so calm and professional and just let you get on with the business of labour. I spent my early labour in the ‘sensory room’ where it was dark and relaxing with gentle music and aromatherapy oil burning. I had bean bags to lean on and a birth ball to sit on. When I got to 8 cm dilated (with no drugs) I transferred into the dolphin room (aptly named because of the deep pool). The warm water was just what I needed as I was really howling the place down by then! It wasn’t long before my baby boy was born into the water and into my and Lynda’s (the midwife) hands. He looked into my eyes and I fell in love instantly and all the pain of labour just melted away. I was on cloud nine. I did it.
At a homebirth, you are the guest. This puts the woman in control. Homebirth truly empowers the woman and enables the midwife to be ‘with woman’ without interruption.Midwifery caseloading
Caseloading teams of midwives provide total care for women and their babies throughout pregnancy until 6 weeks post delivery. Midwifery caseloading teams offer hospital, community maternity unit and homebirths. Although this is predominantly primary maternity care, midwives will usually continue caring for women whose pregnancies become complicated but in conjunction with the hospital obstetrician. Caseloading midwives will often work in small teams and spend time getting to know a group of women, focusing on their individual needs and working in partnership with the women. Within NHS trusts this can often be as many as 30 women a year, depending on whether the midwife works full or part time. In one area of the UK, caseloading exists in contract between a group of self-employed midwives and an acute trust. Walsh (1999) explored caseloading midwifery using an ethnographic approach and described the caseload midwife as a ‘professional friend’ to the woman. Midwifery 2020 (DH 2010) discusses caseloading midwifery as a model that demonstrates positive benefits for women and for their midwives.
One practice in South London (the Albany Practice) was evaluated by Sandall et al. (2001). They describe how the normal birth rate, the homebirth rate and breastfeeding rates all increased for women being caseloaded by the midwives at that practice. Rawnson et al. (2009) explored the benefits of student midwives undertaking caseload midwifery as part of their education and found that the experience was extremely valuable for both the student midwife and the woman and her family. Midwifery 2020 (DH 2010) recommends that women receive continuity of care and suggests that the midwife is the co-ordinator of care with the support of the multidisciplinary team where appropriate.
Homebirth
There is a large body of evidence that suggests that homebirth is at least as safe as hospital birth for healthy pregnant women. The Birthplace Plus Study (Birthplace in England Collaborative Group 2011) describes how morbidity is higher among women who have babies in an institutionalised setting such as large consultant-led units, and a large majority of women who experienced both hospital and home delivery preferred the homebirth. More recently, the Birthplace Plus Study has shown that low-risk women who choose to give birth in consultant-led units are three times more likely to end up having an emergency caesarean section and twice as likely to need an instrumental delivery (Birthplace in England Collaborative Group 2011). A Cochrane review by Olsen & Jewell (2005) found no compelling evidence to suggest that hospital birth was safer than homebirth for low-risk women.
I was pregnant with my first baby and really keen to plan a homebirth. However, when I went to see the midwife, she told me that I couldn’t have a homebirth with my first child as I had an ‘untried pelvis’. She was quite adamant about this. I had really wanted my midwife’s support. My partner was nervous about the idea of homebirth and I was hoping that the midwife would put his mind at rest. After the midwife implied it was dangerous, my partner said there was no way he would let me have the baby at home. I ended up in hospital with a ventouse and a third-degree tear. I wish I had stayed at home. I wish my midwife had supported my choice. Instead, I felt cajoled into doing something I didn’t want to do. I must admit, I felt a bit powerless; I am sure my postnatal depression has something to do with feeling as though I had no control over my decisions.This all had a big impact on my relationship with my partner and caused us to drift apart. I am not sure whether my postnatal depression was the cause or whether it was just the fact that I felt so disempowered by the whole birthing process. I wish midwives and doctors understood sometimes that yes, it is essential that a healthy baby is the outcome of the birth experience but also a woman’s mental health is vital too.
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